hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|MA,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
"Lifespan of Massachusetts – Fall River Inc, DBA Saint Anne's Hospital",    2025-03-21,2.0.0,Saint Anne's Hospital,"795 Middle St, Fall River MA 02721",22-0020,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,code|5,code|5|type,modifiers,setting,billing_class,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,standard_charge|min,standard_charge|max,additional_generic_notes,standard_charge|Aetna|Aetna|negotiated_dollar,standard_charge|Aetna|Aetna|negotiated_percentage,standard_charge|Aetna|Aetna|negotiated_algorithm,standard_charge|Aetna|Aetna|methodology,estimated_amount|Aetna|Aetna,additional_payer_notes|Aetna|Aetna,standard_charge|Aetna Medicare Advantage|Aetna Medicare Advantage|negotiated_dollar,standard_charge|Aetna Medicare Advantage|Aetna Medicare Advantage|negotiated_percentage,standard_charge|Aetna Medicare Advantage|Aetna Medicare Advantage|negotiated_algorithm,standard_charge|Aetna Medicare Advantage|Aetna Medicare Advantage|methodology,estimated_amount|Aetna Medicare Advantage|Aetna Medicare Advantage,additional_payer_notes|Aetna Medicare Advantage|Aetna Medicare Advantage,standard_charge|Assurant|Assurant|negotiated_dollar,standard_charge|Assurant|Assurant|negotiated_percentage,standard_charge|Assurant|Assurant|negotiated_algorithm,standard_charge|Assurant|Assurant|methodology,estimated_amount|Assurant|Assurant,additional_payer_notes|Assurant|Assurant,standard_charge|BCBS HMO Blue|BCBS HMO Blue|negotiated_dollar,standard_charge|BCBS HMO Blue|BCBS HMO Blue|negotiated_percentage,standard_charge|BCBS HMO Blue|BCBS HMO Blue|negotiated_algorithm,standard_charge|BCBS HMO Blue|BCBS HMO Blue|methodology,estimated_amount|BCBS HMO Blue|BCBS HMO Blue,additional_payer_notes|BCBS HMO Blue|BCBS HMO Blue,standard_charge|BCBS Indemnity|BCBS Indemnity|negotiated_dollar,standard_charge|BCBS Indemnity|BCBS Indemnity|negotiated_percentage,standard_charge|BCBS Indemnity|BCBS Indemnity|negotiated_algorithm,standard_charge|BCBS Indemnity|BCBS Indemnity|methodology,estimated_amount|BCBS Indemnity|BCBS Indemnity,additional_payer_notes|BCBS Indemnity|BCBS Indemnity,standard_charge|BCBS Medicare|BCBS Medicare|negotiated_dollar,standard_charge|BCBS Medicare|BCBS Medicare|negotiated_percentage,standard_charge|BCBS Medicare|BCBS Medicare|negotiated_algorithm,standard_charge|BCBS Medicare|BCBS Medicare|methodology,estimated_amount|BCBS Medicare|BCBS Medicare,additional_payer_notes|BCBS Medicare|BCBS Medicare,standard_charge|BCBS PPO|BCBS PPO|negotiated_dollar,standard_charge|BCBS PPO|BCBS PPO|negotiated_percentage,standard_charge|BCBS PPO|BCBS PPO|negotiated_algorithm,standard_charge|BCBS PPO|BCBS PPO|methodology,estimated_amount|BCBS PPO|BCBS PPO,additional_payer_notes|BCBS PPO|BCBS PPO,standard_charge|Beacon Commercial|Beacon Commercial|negotiated_dollar,standard_charge|Beacon Commercial|Beacon Commercial|negotiated_percentage,standard_charge|Beacon Commercial|Beacon Commercial|negotiated_algorithm,standard_charge|Beacon Commercial|Beacon Commercial|methodology,estimated_amount|Beacon Commercial|Beacon Commercial,additional_payer_notes|Beacon Commercial|Beacon Commercial,standard_charge|Beacon Health NHP|Beacon Health NHP|negotiated_dollar,standard_charge|Beacon Health NHP|Beacon Health NHP|negotiated_percentage,standard_charge|Beacon Health NHP|Beacon Health NHP|negotiated_algorithm,standard_charge|Beacon Health NHP|Beacon Health NHP|methodology,estimated_amount|Beacon Health NHP|Beacon Health NHP,additional_payer_notes|Beacon Health NHP|Beacon Health NHP,standard_charge|Beacon Medicaid Managed|Beacon Medicaid Managed|negotiated_dollar,standard_charge|Beacon Medicaid Managed|Beacon Medicaid Managed|negotiated_percentage,standard_charge|Beacon Medicaid Managed|Beacon Medicaid Managed|negotiated_algorithm,standard_charge|Beacon Medicaid Managed|Beacon Medicaid Managed|methodology,estimated_amount|Beacon Medicaid Managed|Beacon Medicaid Managed,additional_payer_notes|Beacon Medicaid Managed|Beacon Medicaid Managed,standard_charge|Beacon Medicare Managed|Beacon Medicare Managed|negotiated_dollar,standard_charge|Beacon Medicare Managed|Beacon Medicare Managed|negotiated_percentage,standard_charge|Beacon Medicare Managed|Beacon Medicare Managed|negotiated_algorithm,standard_charge|Beacon Medicare Managed|Beacon Medicare Managed|methodology,estimated_amount|Beacon Medicare Managed|Beacon Medicare Managed,additional_payer_notes|Beacon Medicare Managed|Beacon Medicare Managed,standard_charge|BMC Healthnet Well Sense|BMC Healthnet Well Sense|negotiated_dollar,standard_charge|BMC Healthnet Well Sense|BMC Healthnet Well Sense|negotiated_percentage,standard_charge|BMC Healthnet Well Sense|BMC Healthnet Well Sense|negotiated_algorithm,standard_charge|BMC Healthnet Well Sense|BMC Healthnet Well Sense|methodology,estimated_amount|BMC Healthnet Well Sense|BMC Healthnet Well Sense,additional_payer_notes|BMC Healthnet Well Sense|BMC Healthnet Well Sense,standard_charge|BMC Hlthnet|BMC Hlthnet|negotiated_dollar,standard_charge|BMC Hlthnet|BMC Hlthnet|negotiated_percentage,standard_charge|BMC Hlthnet|BMC Hlthnet|negotiated_algorithm,standard_charge|BMC Hlthnet|BMC Hlthnet|methodology,estimated_amount|BMC Hlthnet|BMC Hlthnet,additional_payer_notes|BMC Hlthnet|BMC Hlthnet,standard_charge|BMC Hlthnet Medicaid|BMC Hlthnet Medicaid|negotiated_dollar,standard_charge|BMC Hlthnet Medicaid|BMC Hlthnet Medicaid|negotiated_percentage,standard_charge|BMC Hlthnet Medicaid|BMC Hlthnet Medicaid|negotiated_algorithm,standard_charge|BMC Hlthnet Medicaid|BMC Hlthnet Medicaid|methodology,estimated_amount|BMC Hlthnet Medicaid|BMC Hlthnet Medicaid,additional_payer_notes|BMC Hlthnet Medicaid|BMC Hlthnet Medicaid,standard_charge|BMC Hlthnet-Silver|BMC Hlthnet-Silver|negotiated_dollar,standard_charge|BMC Hlthnet-Silver|BMC Hlthnet-Silver|negotiated_percentage,standard_charge|BMC Hlthnet-Silver|BMC Hlthnet-Silver|negotiated_algorithm,standard_charge|BMC Hlthnet-Silver|BMC Hlthnet-Silver|methodology,estimated_amount|BMC Hlthnet-Silver|BMC Hlthnet-Silver,additional_payer_notes|BMC Hlthnet-Silver|BMC Hlthnet-Silver,standard_charge|BMC WellSense Senior Care Options|BMC WellSense Senior Care Options|negotiated_dollar,standard_charge|BMC WellSense Senior Care Options|BMC WellSense Senior Care Options|negotiated_percentage,standard_charge|BMC WellSense Senior Care Options|BMC WellSense Senior Care Options|negotiated_algorithm,standard_charge|BMC WellSense Senior Care Options|BMC WellSense Senior Care Options|methodology,estimated_amount|BMC WellSense Senior Care Options|BMC WellSense Senior Care Options,additional_payer_notes|BMC WellSense Senior Care Options|BMC WellSense Senior Care Options,standard_charge|CeltiCare CHIP|CeltiCare CHIP|negotiated_dollar,standard_charge|CeltiCare CHIP|CeltiCare CHIP|negotiated_percentage,standard_charge|CeltiCare CHIP|CeltiCare CHIP|negotiated_algorithm,standard_charge|CeltiCare CHIP|CeltiCare CHIP|methodology,estimated_amount|CeltiCare CHIP|CeltiCare CHIP,additional_payer_notes|CeltiCare CHIP|CeltiCare CHIP,standard_charge|CeltiCare Choice|CeltiCare Choice|negotiated_dollar,standard_charge|CeltiCare Choice|CeltiCare Choice|negotiated_percentage,standard_charge|CeltiCare Choice|CeltiCare Choice|negotiated_algorithm,standard_charge|CeltiCare Choice|CeltiCare Choice|methodology,estimated_amount|CeltiCare Choice|CeltiCare Choice,additional_payer_notes|CeltiCare Choice|CeltiCare Choice,standard_charge|CeltiCare Medicaid CarePlus|CeltiCare Medicaid CarePlus|negotiated_dollar,standard_charge|CeltiCare Medicaid CarePlus|CeltiCare Medicaid CarePlus|negotiated_percentage,standard_charge|CeltiCare Medicaid CarePlus|CeltiCare Medicaid CarePlus|negotiated_algorithm,standard_charge|CeltiCare Medicaid CarePlus|CeltiCare Medicaid CarePlus|methodology,estimated_amount|CeltiCare Medicaid CarePlus|CeltiCare Medicaid CarePlus,additional_payer_notes|CeltiCare Medicaid CarePlus|CeltiCare Medicaid CarePlus,standard_charge|Cenpatico Behavioral Health|Cenpatico Behavioral Health|negotiated_dollar,standard_charge|Cenpatico Behavioral Health|Cenpatico Behavioral Health|negotiated_percentage,standard_charge|Cenpatico Behavioral Health|Cenpatico Behavioral Health|negotiated_algorithm,standard_charge|Cenpatico Behavioral Health|Cenpatico Behavioral Health|methodology,estimated_amount|Cenpatico Behavioral Health|Cenpatico Behavioral Health,additional_payer_notes|Cenpatico Behavioral Health|Cenpatico Behavioral Health,standard_charge|Champus|Champus|negotiated_dollar,standard_charge|Champus|Champus|negotiated_percentage,standard_charge|Champus|Champus|negotiated_algorithm,standard_charge|Champus|Champus|methodology,estimated_amount|Champus|Champus,additional_payer_notes|Champus|Champus,standard_charge|CIGNA Healthcare|CIGNA Healthcare|negotiated_dollar,standard_charge|CIGNA Healthcare|CIGNA Healthcare|negotiated_percentage,standard_charge|CIGNA Healthcare|CIGNA Healthcare|negotiated_algorithm,standard_charge|CIGNA Healthcare|CIGNA Healthcare|methodology,estimated_amount|CIGNA Healthcare|CIGNA Healthcare,additional_payer_notes|CIGNA Healthcare|CIGNA Healthcare,standard_charge|CIGNA Medicare|CIGNA Medicare|negotiated_dollar,standard_charge|CIGNA Medicare|CIGNA Medicare|negotiated_percentage,standard_charge|CIGNA Medicare|CIGNA Medicare|negotiated_algorithm,standard_charge|CIGNA Medicare|CIGNA Medicare|methodology,estimated_amount|CIGNA Medicare|CIGNA Medicare,additional_payer_notes|CIGNA Medicare|CIGNA Medicare,standard_charge|Commercial Non-Contracted|Commercial Non-Contracted|negotiated_dollar,standard_charge|Commercial Non-Contracted|Commercial Non-Contracted|negotiated_percentage,standard_charge|Commercial Non-Contracted|Commercial Non-Contracted|negotiated_algorithm,standard_charge|Commercial Non-Contracted|Commercial Non-Contracted|methodology,estimated_amount|Commercial Non-Contracted|Commercial Non-Contracted,additional_payer_notes|Commercial Non-Contracted|Commercial Non-Contracted,standard_charge|COMMERCIAL-HISTORICAL PAF|COMMERCIAL-HISTORICAL PAF|negotiated_dollar,standard_charge|COMMERCIAL-HISTORICAL PAF|COMMERCIAL-HISTORICAL PAF|negotiated_percentage,standard_charge|COMMERCIAL-HISTORICAL PAF|COMMERCIAL-HISTORICAL PAF|negotiated_algorithm,standard_charge|COMMERCIAL-HISTORICAL PAF|COMMERCIAL-HISTORICAL PAF|methodology,estimated_amount|COMMERCIAL-HISTORICAL PAF|COMMERCIAL-HISTORICAL PAF,additional_payer_notes|COMMERCIAL-HISTORICAL PAF|COMMERCIAL-HISTORICAL PAF,standard_charge|Commonwealth Care Alliance|Commonwealth Care Alliance|negotiated_dollar,standard_charge|Commonwealth Care Alliance|Commonwealth Care Alliance|negotiated_percentage,standard_charge|Commonwealth Care Alliance|Commonwealth Care Alliance|negotiated_algorithm,standard_charge|Commonwealth Care Alliance|Commonwealth Care Alliance|methodology,estimated_amount|Commonwealth Care Alliance|Commonwealth Care Alliance,additional_payer_notes|Commonwealth Care Alliance|Commonwealth Care Alliance,standard_charge|Commonwealth Care Alliance-PPO|Commonwealth Care Alliance-PPO|negotiated_dollar,standard_charge|Commonwealth Care Alliance-PPO|Commonwealth Care Alliance-PPO|negotiated_percentage,standard_charge|Commonwealth Care Alliance-PPO|Commonwealth Care Alliance-PPO|negotiated_algorithm,standard_charge|Commonwealth Care Alliance-PPO|Commonwealth Care Alliance-PPO|methodology,estimated_amount|Commonwealth Care Alliance-PPO|Commonwealth Care Alliance-PPO,additional_payer_notes|Commonwealth Care Alliance-PPO|Commonwealth Care Alliance-PPO,standard_charge|COVID19 HRSA UNINSURED|COVID19 HRSA UNINSURED|negotiated_dollar,standard_charge|COVID19 HRSA UNINSURED|COVID19 HRSA UNINSURED|negotiated_percentage,standard_charge|COVID19 HRSA UNINSURED|COVID19 HRSA UNINSURED|negotiated_algorithm,standard_charge|COVID19 HRSA UNINSURED|COVID19 HRSA UNINSURED|methodology,estimated_amount|COVID19 HRSA UNINSURED|COVID19 HRSA UNINSURED,additional_payer_notes|COVID19 HRSA UNINSURED|COVID19 HRSA UNINSURED,standard_charge|Elder Services|Elder Services|negotiated_dollar,standard_charge|Elder Services|Elder Services|negotiated_percentage,standard_charge|Elder Services|Elder Services|negotiated_algorithm,standard_charge|Elder Services|Elder Services|methodology,estimated_amount|Elder Services|Elder Services,additional_payer_notes|Elder Services|Elder Services,standard_charge|Employer Direct Healthcare|Employer Direct Healthcare|negotiated_dollar,standard_charge|Employer Direct Healthcare|Employer Direct Healthcare|negotiated_percentage,standard_charge|Employer Direct Healthcare|Employer Direct Healthcare|negotiated_algorithm,standard_charge|Employer Direct Healthcare|Employer Direct Healthcare|methodology,estimated_amount|Employer Direct Healthcare|Employer Direct Healthcare,additional_payer_notes|Employer Direct Healthcare|Employer Direct Healthcare,standard_charge|Eternal Health Medicare Advantage|Eternal Health Medicare Advantage|negotiated_dollar,standard_charge|Eternal Health Medicare Advantage|Eternal Health Medicare Advantage|negotiated_percentage,standard_charge|Eternal Health Medicare Advantage|Eternal Health Medicare Advantage|negotiated_algorithm,standard_charge|Eternal Health Medicare Advantage|Eternal Health Medicare Advantage|methodology,estimated_amount|Eternal Health Medicare Advantage|Eternal Health Medicare Advantage,additional_payer_notes|Eternal Health Medicare Advantage|Eternal Health Medicare Advantage,standard_charge|Fallon|Fallon|negotiated_dollar,standard_charge|Fallon|Fallon|negotiated_percentage,standard_charge|Fallon|Fallon|negotiated_algorithm,standard_charge|Fallon|Fallon|methodology,estimated_amount|Fallon|Fallon,additional_payer_notes|Fallon|Fallon,standard_charge|Fallon Medicaid Managed Care|Fallon Medicaid Managed Care|negotiated_dollar,standard_charge|Fallon Medicaid Managed Care|Fallon Medicaid Managed Care|negotiated_percentage,standard_charge|Fallon Medicaid Managed Care|Fallon Medicaid Managed Care|negotiated_algorithm,standard_charge|Fallon Medicaid Managed Care|Fallon Medicaid Managed Care|methodology,estimated_amount|Fallon Medicaid Managed Care|Fallon Medicaid Managed Care,additional_payer_notes|Fallon Medicaid Managed Care|Fallon Medicaid Managed Care,standard_charge|Fallon Medicare Managed Care|Fallon Medicare Managed Care|negotiated_dollar,standard_charge|Fallon Medicare Managed Care|Fallon Medicare Managed Care|negotiated_percentage,standard_charge|Fallon Medicare Managed Care|Fallon Medicare Managed Care|negotiated_algorithm,standard_charge|Fallon Medicare Managed Care|Fallon Medicare Managed Care|methodology,estimated_amount|Fallon Medicare Managed Care|Fallon Medicare Managed Care,additional_payer_notes|Fallon Medicare Managed Care|Fallon Medicare Managed Care,standard_charge|Harvard Pilgrim Managed Care|Harvard Pilgrim Managed Care|negotiated_dollar,standard_charge|Harvard Pilgrim Managed Care|Harvard Pilgrim Managed Care|negotiated_percentage,standard_charge|Harvard Pilgrim Managed Care|Harvard Pilgrim Managed Care|negotiated_algorithm,standard_charge|Harvard Pilgrim Managed Care|Harvard Pilgrim Managed Care|methodology,estimated_amount|Harvard Pilgrim Managed Care|Harvard Pilgrim Managed Care,additional_payer_notes|Harvard Pilgrim Managed Care|Harvard Pilgrim Managed Care,standard_charge|Harvard Pilgrim Managed Care-Limited/Tiered|Harvard Pilgrim Managed Care-Limited/Tiered|negotiated_dollar,standard_charge|Harvard Pilgrim Managed Care-Limited/Tiered|Harvard Pilgrim Managed Care-Limited/Tiered|negotiated_percentage,standard_charge|Harvard Pilgrim Managed Care-Limited/Tiered|Harvard Pilgrim Managed Care-Limited/Tiered|negotiated_algorithm,standard_charge|Harvard Pilgrim Managed Care-Limited/Tiered|Harvard Pilgrim Managed Care-Limited/Tiered|methodology,estimated_amount|Harvard Pilgrim Managed Care-Limited/Tiered|Harvard Pilgrim Managed Care-Limited/Tiered,additional_payer_notes|Harvard Pilgrim Managed Care-Limited/Tiered|Harvard Pilgrim Managed Care-Limited/Tiered,standard_charge|Harvard Pilgrim Managed Care-Self Insured|Harvard Pilgrim Managed Care-Self Insured|negotiated_dollar,standard_charge|Harvard Pilgrim Managed Care-Self Insured|Harvard Pilgrim Managed Care-Self Insured|negotiated_percentage,standard_charge|Harvard Pilgrim Managed Care-Self Insured|Harvard Pilgrim Managed Care-Self Insured|negotiated_algorithm,standard_charge|Harvard Pilgrim Managed Care-Self Insured|Harvard Pilgrim Managed Care-Self Insured|methodology,estimated_amount|Harvard Pilgrim Managed Care-Self Insured|Harvard Pilgrim Managed Care-Self Insured,additional_payer_notes|Harvard Pilgrim Managed Care-Self Insured|Harvard Pilgrim Managed Care-Self Insured,standard_charge|Harvard Pilgrim Medicare Managed Care|Harvard Pilgrim Medicare Managed Care|negotiated_dollar,standard_charge|Harvard Pilgrim Medicare Managed Care|Harvard Pilgrim Medicare Managed Care|negotiated_percentage,standard_charge|Harvard Pilgrim Medicare Managed Care|Harvard Pilgrim Medicare Managed Care|negotiated_algorithm,standard_charge|Harvard Pilgrim Medicare Managed Care|Harvard Pilgrim Medicare Managed Care|methodology,estimated_amount|Harvard Pilgrim Medicare Managed Care|Harvard Pilgrim Medicare Managed Care,additional_payer_notes|Harvard Pilgrim Medicare Managed Care|Harvard Pilgrim Medicare Managed Care,standard_charge|HCVM|HCVM|negotiated_dollar,standard_charge|HCVM|HCVM|negotiated_percentage,standard_charge|HCVM|HCVM|negotiated_algorithm,standard_charge|HCVM|HCVM|methodology,estimated_amount|HCVM|HCVM,additional_payer_notes|HCVM|HCVM,standard_charge|Health Safety Net (HSN)|Health Safety Net (HSN)|negotiated_dollar,standard_charge|Health Safety Net (HSN)|Health Safety Net (HSN)|negotiated_percentage,standard_charge|Health Safety Net (HSN)|Health Safety Net (HSN)|negotiated_algorithm,standard_charge|Health Safety Net (HSN)|Health Safety Net (HSN)|methodology,estimated_amount|Health Safety Net (HSN)|Health Safety Net (HSN),additional_payer_notes|Health Safety Net (HSN)|Health Safety Net (HSN),standard_charge|Hospice|Hospice|negotiated_dollar,standard_charge|Hospice|Hospice|negotiated_percentage,standard_charge|Hospice|Hospice|negotiated_algorithm,standard_charge|Hospice|Hospice|methodology,estimated_amount|Hospice|Hospice,additional_payer_notes|Hospice|Hospice,standard_charge|HSN-ER Bad Debt|HSN-ER Bad Debt|negotiated_dollar,standard_charge|HSN-ER Bad Debt|HSN-ER Bad Debt|negotiated_percentage,standard_charge|HSN-ER Bad Debt|HSN-ER Bad Debt|negotiated_algorithm,standard_charge|HSN-ER Bad Debt|HSN-ER Bad Debt|methodology,estimated_amount|HSN-ER Bad Debt|HSN-ER Bad Debt,additional_payer_notes|HSN-ER Bad Debt|HSN-ER Bad Debt,standard_charge|Humana|Humana|negotiated_dollar,standard_charge|Humana|Humana|negotiated_percentage,standard_charge|Humana|Humana|negotiated_algorithm,standard_charge|Humana|Humana|methodology,estimated_amount|Humana|Humana,additional_payer_notes|Humana|Humana,standard_charge|Humana Medicare|Humana Medicare|negotiated_dollar,standard_charge|Humana Medicare|Humana Medicare|negotiated_percentage,standard_charge|Humana Medicare|Humana Medicare|negotiated_algorithm,standard_charge|Humana Medicare|Humana Medicare|methodology,estimated_amount|Humana Medicare|Humana Medicare,additional_payer_notes|Humana Medicare|Humana Medicare,standard_charge|Longevity Health Plan Medicare Advantage|Longevity Health Plan Medicare Advantage|negotiated_dollar,standard_charge|Longevity Health Plan Medicare Advantage|Longevity Health Plan Medicare Advantage|negotiated_percentage,standard_charge|Longevity Health Plan Medicare Advantage|Longevity Health Plan Medicare Advantage|negotiated_algorithm,standard_charge|Longevity Health Plan Medicare Advantage|Longevity Health Plan Medicare Advantage|methodology,estimated_amount|Longevity Health Plan Medicare Advantage|Longevity Health Plan Medicare Advantage,additional_payer_notes|Longevity Health Plan Medicare Advantage|Longevity Health Plan Medicare Advantage,standard_charge|Mass DOC - Correct Care|Mass DOC - Correct Care|negotiated_dollar,standard_charge|Mass DOC - Correct Care|Mass DOC - Correct Care|negotiated_percentage,standard_charge|Mass DOC - Correct Care|Mass DOC - Correct Care|negotiated_algorithm,standard_charge|Mass DOC - Correct Care|Mass DOC - Correct Care|methodology,estimated_amount|Mass DOC - Correct Care|Mass DOC - Correct Care,additional_payer_notes|Mass DOC - Correct Care|Mass DOC - Correct Care,standard_charge|Mass Rehab|Mass Rehab|negotiated_dollar,standard_charge|Mass Rehab|Mass Rehab|negotiated_percentage,standard_charge|Mass Rehab|Mass Rehab|negotiated_algorithm,standard_charge|Mass Rehab|Mass Rehab|methodology,estimated_amount|Mass Rehab|Mass Rehab,additional_payer_notes|Mass Rehab|Mass Rehab,standard_charge|MBHP|MBHP|negotiated_dollar,standard_charge|MBHP|MBHP|negotiated_percentage,standard_charge|MBHP|MBHP|negotiated_algorithm,standard_charge|MBHP|MBHP|methodology,estimated_amount|MBHP|MBHP,additional_payer_notes|MBHP|MBHP,standard_charge|MBHP Steward ACO|MBHP Steward ACO|negotiated_dollar,standard_charge|MBHP Steward ACO|MBHP Steward ACO|negotiated_percentage,standard_charge|MBHP Steward ACO|MBHP Steward ACO|negotiated_algorithm,standard_charge|MBHP Steward ACO|MBHP Steward ACO|methodology,estimated_amount|MBHP Steward ACO|MBHP Steward ACO,additional_payer_notes|MBHP Steward ACO|MBHP Steward ACO,standard_charge|Medicaid|Medicaid|negotiated_dollar,standard_charge|Medicaid|Medicaid|negotiated_percentage,standard_charge|Medicaid|Medicaid|negotiated_algorithm,standard_charge|Medicaid|Medicaid|methodology,estimated_amount|Medicaid|Medicaid,additional_payer_notes|Medicaid|Medicaid,standard_charge|Medicaid Managed - Miscellaneous|Medicaid Managed - Miscellaneous|negotiated_dollar,standard_charge|Medicaid Managed - Miscellaneous|Medicaid Managed - Miscellaneous|negotiated_percentage,standard_charge|Medicaid Managed - Miscellaneous|Medicaid Managed - Miscellaneous|negotiated_algorithm,standard_charge|Medicaid Managed - Miscellaneous|Medicaid Managed - Miscellaneous|methodology,estimated_amount|Medicaid Managed - Miscellaneous|Medicaid Managed - Miscellaneous,additional_payer_notes|Medicaid Managed - Miscellaneous|Medicaid Managed - Miscellaneous,standard_charge|Medicaid Out of State|Medicaid Out of State|negotiated_dollar,standard_charge|Medicaid Out of State|Medicaid Out of State|negotiated_percentage,standard_charge|Medicaid Out of State|Medicaid Out of State|negotiated_algorithm,standard_charge|Medicaid Out of State|Medicaid Out of State|methodology,estimated_amount|Medicaid Out of State|Medicaid Out of State,additional_payer_notes|Medicaid Out of State|Medicaid Out of State,standard_charge|Medicare|Medicare|negotiated_dollar,standard_charge|Medicare|Medicare|negotiated_percentage,standard_charge|Medicare|Medicare|negotiated_algorithm,standard_charge|Medicare|Medicare|methodology,estimated_amount|Medicare|Medicare,additional_payer_notes|Medicare|Medicare,standard_charge|Medicare Managed Miscellaneous|Medicare Managed Miscellaneous|negotiated_dollar,standard_charge|Medicare Managed Miscellaneous|Medicare Managed Miscellaneous|negotiated_percentage,standard_charge|Medicare Managed Miscellaneous|Medicare Managed Miscellaneous|negotiated_algorithm,standard_charge|Medicare Managed Miscellaneous|Medicare Managed Miscellaneous|methodology,estimated_amount|Medicare Managed Miscellaneous|Medicare Managed Miscellaneous,additional_payer_notes|Medicare Managed Miscellaneous|Medicare Managed Miscellaneous,standard_charge|Neighborhood Health CHIP|Neighborhood Health CHIP|negotiated_dollar,standard_charge|Neighborhood Health CHIP|Neighborhood Health CHIP|negotiated_percentage,standard_charge|Neighborhood Health CHIP|Neighborhood Health CHIP|negotiated_algorithm,standard_charge|Neighborhood Health CHIP|Neighborhood Health CHIP|methodology,estimated_amount|Neighborhood Health CHIP|Neighborhood Health CHIP,additional_payer_notes|Neighborhood Health CHIP|Neighborhood Health CHIP,standard_charge|Neighborhood Health HMO|Neighborhood Health HMO|negotiated_dollar,standard_charge|Neighborhood Health HMO|Neighborhood Health HMO|negotiated_percentage,standard_charge|Neighborhood Health HMO|Neighborhood Health HMO|negotiated_algorithm,standard_charge|Neighborhood Health HMO|Neighborhood Health HMO|methodology,estimated_amount|Neighborhood Health HMO|Neighborhood Health HMO,additional_payer_notes|Neighborhood Health HMO|Neighborhood Health HMO,standard_charge|Neighborhood Health Medicaid|Neighborhood Health Medicaid|negotiated_dollar,standard_charge|Neighborhood Health Medicaid|Neighborhood Health Medicaid|negotiated_percentage,standard_charge|Neighborhood Health Medicaid|Neighborhood Health Medicaid|negotiated_algorithm,standard_charge|Neighborhood Health Medicaid|Neighborhood Health Medicaid|methodology,estimated_amount|Neighborhood Health Medicaid|Neighborhood Health Medicaid,additional_payer_notes|Neighborhood Health Medicaid|Neighborhood Health Medicaid,standard_charge|Neighborhood Health Medicare Advantage|Neighborhood Health Medicare Advantage|negotiated_dollar,standard_charge|Neighborhood Health Medicare Advantage|Neighborhood Health Medicare Advantage|negotiated_percentage,standard_charge|Neighborhood Health Medicare Advantage|Neighborhood Health Medicare Advantage|negotiated_algorithm,standard_charge|Neighborhood Health Medicare Advantage|Neighborhood Health Medicare Advantage|methodology,estimated_amount|Neighborhood Health Medicare Advantage|Neighborhood Health Medicare Advantage,additional_payer_notes|Neighborhood Health Medicare Advantage|Neighborhood Health Medicare Advantage,standard_charge|Neighborhood Health RI|Neighborhood Health RI|negotiated_dollar,standard_charge|Neighborhood Health RI|Neighborhood Health RI|negotiated_percentage,standard_charge|Neighborhood Health RI|Neighborhood Health RI|negotiated_algorithm,standard_charge|Neighborhood Health RI|Neighborhood Health RI|methodology,estimated_amount|Neighborhood Health RI|Neighborhood Health RI,additional_payer_notes|Neighborhood Health RI|Neighborhood Health RI,standard_charge|Network Health Medicaid|Network Health Medicaid|negotiated_dollar,standard_charge|Network Health Medicaid|Network Health Medicaid|negotiated_percentage,standard_charge|Network Health Medicaid|Network Health Medicaid|negotiated_algorithm,standard_charge|Network Health Medicaid|Network Health Medicaid|methodology,estimated_amount|Network Health Medicaid|Network Health Medicaid,additional_payer_notes|Network Health Medicaid|Network Health Medicaid,standard_charge|Network Health QHP Non-Subsidized|Network Health QHP Non-Subsidized|negotiated_dollar,standard_charge|Network Health QHP Non-Subsidized|Network Health QHP Non-Subsidized|negotiated_percentage,standard_charge|Network Health QHP Non-Subsidized|Network Health QHP Non-Subsidized|negotiated_algorithm,standard_charge|Network Health QHP Non-Subsidized|Network Health QHP Non-Subsidized|methodology,estimated_amount|Network Health QHP Non-Subsidized|Network Health QHP Non-Subsidized,additional_payer_notes|Network Health QHP Non-Subsidized|Network Health QHP Non-Subsidized,standard_charge|Network Health QHP Subsidized|Network Health QHP Subsidized|negotiated_dollar,standard_charge|Network Health QHP Subsidized|Network Health QHP Subsidized|negotiated_percentage,standard_charge|Network Health QHP Subsidized|Network Health QHP Subsidized|negotiated_algorithm,standard_charge|Network Health QHP Subsidized|Network Health QHP Subsidized|methodology,estimated_amount|Network Health QHP Subsidized|Network Health QHP Subsidized,additional_payer_notes|Network Health QHP Subsidized|Network Health QHP Subsidized,standard_charge|RI Blue Cross Medicare Advantage|RI Blue Cross Medicare Advantage|negotiated_dollar,standard_charge|RI Blue Cross Medicare Advantage|RI Blue Cross Medicare Advantage|negotiated_percentage,standard_charge|RI Blue Cross Medicare Advantage|RI Blue Cross Medicare Advantage|negotiated_algorithm,standard_charge|RI Blue Cross Medicare Advantage|RI Blue Cross Medicare Advantage|methodology,estimated_amount|RI Blue Cross Medicare Advantage|RI Blue Cross Medicare Advantage,additional_payer_notes|RI Blue Cross Medicare Advantage|RI Blue Cross Medicare Advantage,standard_charge|Self Pay|Self Pay|negotiated_dollar,standard_charge|Self Pay|Self Pay|negotiated_percentage,standard_charge|Self Pay|Self Pay|negotiated_algorithm,standard_charge|Self Pay|Self Pay|methodology,estimated_amount|Self Pay|Self Pay,additional_payer_notes|Self Pay|Self Pay,standard_charge|SELF PAY ELECTIVE|SELF PAY ELECTIVE|negotiated_dollar,standard_charge|SELF PAY ELECTIVE|SELF PAY ELECTIVE|negotiated_percentage,standard_charge|SELF PAY ELECTIVE|SELF PAY ELECTIVE|negotiated_algorithm,standard_charge|SELF PAY ELECTIVE|SELF PAY ELECTIVE|methodology,estimated_amount|SELF PAY ELECTIVE|SELF PAY ELECTIVE,additional_payer_notes|SELF PAY ELECTIVE|SELF PAY ELECTIVE,standard_charge|SELF PAY EMERGENT|SELF PAY EMERGENT|negotiated_dollar,standard_charge|SELF PAY EMERGENT|SELF PAY EMERGENT|negotiated_percentage,standard_charge|SELF PAY EMERGENT|SELF PAY EMERGENT|negotiated_algorithm,standard_charge|SELF PAY EMERGENT|SELF PAY EMERGENT|methodology,estimated_amount|SELF PAY EMERGENT|SELF PAY EMERGENT,additional_payer_notes|SELF PAY EMERGENT|SELF PAY EMERGENT,standard_charge|Self Pay Non-Traditional|Self Pay Non-Traditional|negotiated_dollar,standard_charge|Self Pay Non-Traditional|Self Pay Non-Traditional|negotiated_percentage,standard_charge|Self Pay Non-Traditional|Self Pay Non-Traditional|negotiated_algorithm,standard_charge|Self Pay Non-Traditional|Self Pay Non-Traditional|methodology,estimated_amount|Self Pay Non-Traditional|Self Pay Non-Traditional,additional_payer_notes|Self Pay Non-Traditional|Self Pay Non-Traditional,standard_charge|Self-Pay Other|Self-Pay Other|negotiated_dollar,standard_charge|Self-Pay Other|Self-Pay Other|negotiated_percentage,standard_charge|Self-Pay Other|Self-Pay Other|negotiated_algorithm,standard_charge|Self-Pay Other|Self-Pay Other|methodology,estimated_amount|Self-Pay Other|Self-Pay Other,additional_payer_notes|Self-Pay Other|Self-Pay Other,standard_charge|Self-Pay Other Facility|Self-Pay Other Facility|negotiated_dollar,standard_charge|Self-Pay Other Facility|Self-Pay Other Facility|negotiated_percentage,standard_charge|Self-Pay Other Facility|Self-Pay Other Facility|negotiated_algorithm,standard_charge|Self-Pay Other Facility|Self-Pay Other Facility|methodology,estimated_amount|Self-Pay Other Facility|Self-Pay Other Facility,additional_payer_notes|Self-Pay Other Facility|Self-Pay Other Facility,standard_charge|Senior Whole Health|Senior Whole Health|negotiated_dollar,standard_charge|Senior Whole Health|Senior Whole Health|negotiated_percentage,standard_charge|Senior Whole Health|Senior Whole Health|negotiated_algorithm,standard_charge|Senior Whole Health|Senior Whole Health|methodology,estimated_amount|Senior Whole Health|Senior Whole Health,additional_payer_notes|Senior Whole Health|Senior Whole Health,standard_charge|Senior Whole Health-Behavioral Health|Senior Whole Health-Behavioral Health|negotiated_dollar,standard_charge|Senior Whole Health-Behavioral Health|Senior Whole Health-Behavioral Health|negotiated_percentage,standard_charge|Senior Whole Health-Behavioral Health|Senior Whole Health-Behavioral Health|negotiated_algorithm,standard_charge|Senior Whole Health-Behavioral Health|Senior Whole Health-Behavioral Health|methodology,estimated_amount|Senior Whole Health-Behavioral Health|Senior Whole Health-Behavioral Health,additional_payer_notes|Senior Whole Health-Behavioral Health|Senior Whole Health-Behavioral Health,standard_charge|Single Case Agreement|Single Case Agreement|negotiated_dollar,standard_charge|Single Case Agreement|Single Case Agreement|negotiated_percentage,standard_charge|Single Case Agreement|Single Case Agreement|negotiated_algorithm,standard_charge|Single Case Agreement|Single Case Agreement|methodology,estimated_amount|Single Case Agreement|Single Case Agreement,additional_payer_notes|Single Case Agreement|Single Case Agreement,standard_charge|THPP Medicare Managed Care|THPP Medicare Managed Care|negotiated_dollar,standard_charge|THPP Medicare Managed Care|THPP Medicare Managed Care|negotiated_percentage,standard_charge|THPP Medicare Managed Care|THPP Medicare Managed Care|negotiated_algorithm,standard_charge|THPP Medicare Managed Care|THPP Medicare Managed Care|methodology,estimated_amount|THPP Medicare Managed Care|THPP Medicare Managed Care,additional_payer_notes|THPP Medicare Managed Care|THPP Medicare Managed Care,standard_charge|Tufts HMO|Tufts HMO|negotiated_dollar,standard_charge|Tufts HMO|Tufts HMO|negotiated_percentage,standard_charge|Tufts HMO|Tufts HMO|negotiated_algorithm,standard_charge|Tufts HMO|Tufts HMO|methodology,estimated_amount|Tufts HMO|Tufts HMO,additional_payer_notes|Tufts HMO|Tufts HMO,standard_charge|Tufts Medicare Managed Care|Tufts Medicare Managed Care|negotiated_dollar,standard_charge|Tufts Medicare Managed Care|Tufts Medicare Managed Care|negotiated_percentage,standard_charge|Tufts Medicare Managed Care|Tufts Medicare Managed Care|negotiated_algorithm,standard_charge|Tufts Medicare Managed Care|Tufts Medicare Managed Care|methodology,estimated_amount|Tufts Medicare Managed Care|Tufts Medicare Managed Care,additional_payer_notes|Tufts Medicare Managed Care|Tufts Medicare Managed Care,standard_charge|Tufts Medicare Managed Care-Steward PCP|Tufts Medicare Managed Care-Steward PCP|negotiated_dollar,standard_charge|Tufts Medicare Managed Care-Steward PCP|Tufts Medicare Managed Care-Steward PCP|negotiated_percentage,standard_charge|Tufts Medicare Managed Care-Steward PCP|Tufts Medicare Managed Care-Steward PCP|negotiated_algorithm,standard_charge|Tufts Medicare Managed Care-Steward PCP|Tufts Medicare Managed Care-Steward PCP|methodology,estimated_amount|Tufts Medicare Managed Care-Steward PCP|Tufts Medicare Managed Care-Steward PCP,additional_payer_notes|Tufts Medicare Managed Care-Steward PCP|Tufts Medicare Managed Care-Steward PCP,"standard_charge|Tufts Plan Spirit	|Tufts Plan Spirit|negotiated_dollar","standard_charge|Tufts Plan Spirit	|Tufts Plan Spirit|negotiated_percentage","standard_charge|Tufts Plan Spirit	|Tufts Plan Spirit|negotiated_algorithm","standard_charge|Tufts Plan Spirit	|Tufts Plan Spirit|methodology","estimated_amount|Tufts Plan Spirit	|Tufts Plan Spirit","additional_payer_notes|Tufts Plan Spirit	|Tufts Plan Spirit",standard_charge|Tufts PPO|Tufts PPO|negotiated_dollar,standard_charge|Tufts PPO|Tufts PPO|negotiated_percentage,standard_charge|Tufts PPO|Tufts PPO|negotiated_algorithm,standard_charge|Tufts PPO|Tufts PPO|methodology,estimated_amount|Tufts PPO|Tufts PPO,additional_payer_notes|Tufts PPO|Tufts PPO,standard_charge|Tufts Select|Tufts Select|negotiated_dollar,standard_charge|Tufts Select|Tufts Select|negotiated_percentage,standard_charge|Tufts Select|Tufts Select|negotiated_algorithm,standard_charge|Tufts Select|Tufts Select|methodology,estimated_amount|Tufts Select|Tufts Select,additional_payer_notes|Tufts Select|Tufts Select,standard_charge|Unicare|Unicare|negotiated_dollar,standard_charge|Unicare|Unicare|negotiated_percentage,standard_charge|Unicare|Unicare|negotiated_algorithm,standard_charge|Unicare|Unicare|methodology,estimated_amount|Unicare|Unicare,additional_payer_notes|Unicare|Unicare,standard_charge|United Behavioral Health Commercial|United Behavioral Health Commercial|negotiated_dollar,standard_charge|United Behavioral Health Commercial|United Behavioral Health Commercial|negotiated_percentage,standard_charge|United Behavioral Health Commercial|United Behavioral Health Commercial|negotiated_algorithm,standard_charge|United Behavioral Health Commercial|United Behavioral Health Commercial|methodology,estimated_amount|United Behavioral Health Commercial|United Behavioral Health Commercial,additional_payer_notes|United Behavioral Health Commercial|United Behavioral Health Commercial,standard_charge|United Behavioral Health Medicaid|United Behavioral Health Medicaid|negotiated_dollar,standard_charge|United Behavioral Health Medicaid|United Behavioral Health Medicaid|negotiated_percentage,standard_charge|United Behavioral Health Medicaid|United Behavioral Health Medicaid|negotiated_algorithm,standard_charge|United Behavioral Health Medicaid|United Behavioral Health Medicaid|methodology,estimated_amount|United Behavioral Health Medicaid|United Behavioral Health Medicaid,additional_payer_notes|United Behavioral Health Medicaid|United Behavioral Health Medicaid,standard_charge|United Behavioral Health Medicare|United Behavioral Health Medicare|negotiated_dollar,standard_charge|United Behavioral Health Medicare|United Behavioral Health Medicare|negotiated_percentage,standard_charge|United Behavioral Health Medicare|United Behavioral Health Medicare|negotiated_algorithm,standard_charge|United Behavioral Health Medicare|United Behavioral Health Medicare|methodology,estimated_amount|United Behavioral Health Medicare|United Behavioral Health Medicare,additional_payer_notes|United Behavioral Health Medicare|United Behavioral Health Medicare,standard_charge|United Health Care|United Health Care|negotiated_dollar,standard_charge|United Health Care|United Health Care|negotiated_percentage,standard_charge|United Health Care|United Health Care|negotiated_algorithm,standard_charge|United Health Care|United Health Care|methodology,estimated_amount|United Health Care|United Health Care,additional_payer_notes|United Health Care|United Health Care,standard_charge|United Health Medicaid|United Health Medicaid|negotiated_dollar,standard_charge|United Health Medicaid|United Health Medicaid|negotiated_percentage,standard_charge|United Health Medicaid|United Health Medicaid|negotiated_algorithm,standard_charge|United Health Medicaid|United Health Medicaid|methodology,estimated_amount|United Health Medicaid|United Health Medicaid,additional_payer_notes|United Health Medicaid|United Health Medicaid,standard_charge|United Health Secure Horizons|United Health Secure Horizons|negotiated_dollar,standard_charge|United Health Secure Horizons|United Health Secure Horizons|negotiated_percentage,standard_charge|United Health Secure Horizons|United Health Secure Horizons|negotiated_algorithm,standard_charge|United Health Secure Horizons|United Health Secure Horizons|methodology,estimated_amount|United Health Secure Horizons|United Health Secure Horizons,additional_payer_notes|United Health Secure Horizons|United Health Secure Horizons,standard_charge|United Medicare Advantage|United Medicare Advantage|negotiated_dollar,standard_charge|United Medicare Advantage|United Medicare Advantage|negotiated_percentage,standard_charge|United Medicare Advantage|United Medicare Advantage|negotiated_algorithm,standard_charge|United Medicare Advantage|United Medicare Advantage|methodology,estimated_amount|United Medicare Advantage|United Medicare Advantage,additional_payer_notes|United Medicare Advantage|United Medicare Advantage,"standard_charge|United Medicare SCO/OneCare	|United Medicare SCO/OneCare	|negotiated_dollar","standard_charge|United Medicare SCO/OneCare	|United Medicare SCO/OneCare	|negotiated_percentage","standard_charge|United Medicare SCO/OneCare	|United Medicare SCO/OneCare	|negotiated_algorithm","standard_charge|United Medicare SCO/OneCare	|United Medicare SCO/OneCare	|methodology","estimated_amount|United Medicare SCO/OneCare	|United Medicare SCO/OneCare	","additional_payer_notes|United Medicare SCO/OneCare	|United Medicare SCO/OneCare	",standard_charge|US Family Health Plan|US Family Health Plan|negotiated_dollar,standard_charge|US Family Health Plan|US Family Health Plan|negotiated_percentage,standard_charge|US Family Health Plan|US Family Health Plan|negotiated_algorithm,standard_charge|US Family Health Plan|US Family Health Plan|methodology,estimated_amount|US Family Health Plan|US Family Health Plan,additional_payer_notes|US Family Health Plan|US Family Health Plan,standard_charge|VA Community Care|VA Community Care|negotiated_dollar,standard_charge|VA Community Care|VA Community Care|negotiated_percentage,standard_charge|VA Community Care|VA Community Care|negotiated_algorithm,standard_charge|VA Community Care|VA Community Care|methodology,estimated_amount|VA Community Care|VA Community Care,additional_payer_notes|VA Community Care|VA Community Care,standard_charge|Value Options|Value Options|negotiated_dollar,standard_charge|Value Options|Value Options|negotiated_percentage,standard_charge|Value Options|Value Options|negotiated_algorithm,standard_charge|Value Options|Value Options|methodology,estimated_amount|Value Options|Value Options,additional_payer_notes|Value Options|Value Options,standard_charge|Veterans Administration|Veterans Administration|negotiated_dollar,standard_charge|Veterans Administration|Veterans Administration|negotiated_percentage,standard_charge|Veterans Administration|Veterans Administration|negotiated_algorithm,standard_charge|Veterans Administration|Veterans Administration|methodology,estimated_amount|Veterans Administration|Veterans Administration,additional_payer_notes|Veterans Administration|Veterans Administration,standard_charge|WellCare Medicare Managed Care|WellCare Medicare Managed Care|negotiated_dollar,standard_charge|WellCare Medicare Managed Care|WellCare Medicare Managed Care|negotiated_percentage,standard_charge|WellCare Medicare Managed Care|WellCare Medicare Managed Care|negotiated_algorithm,standard_charge|WellCare Medicare Managed Care|WellCare Medicare Managed Care|methodology,estimated_amount|WellCare Medicare Managed Care|WellCare Medicare Managed Care,additional_payer_notes|WellCare Medicare Managed Care|WellCare Medicare Managed Care,standard_charge|Workers Comp|Workers Comp|negotiated_dollar,standard_charge|Workers Comp|Workers Comp|negotiated_percentage,standard_charge|Workers Comp|Workers Comp|negotiated_algorithm,standard_charge|Workers Comp|Workers Comp|methodology,estimated_amount|Workers Comp|Workers Comp,additional_payer_notes|Workers Comp|Workers Comp
R&B PRIVATE,1140525110,CDM,110,RC,,,,,,,,inpatient,facility,,,1366.06,1366.06,109.28,8479.78,,1366.06,,,case rate,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,percent of total billed charges,,,697.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1163.47,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,819.64,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,1366.06,,,percent of total billed charges,,,1161.15,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,725.51,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,546.42,,,percent of total billed charges,,,2732.12,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,109.28,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,case rate,,,1161.15,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,683.03,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,804.88,,,percent of total billed charges,,
R&B PRIVATE ISOLATION,1140525164,CDM,164,RC,,,,,,,,inpatient,facility,,,2730,2730,218.4,8479.78,,2730,,,case rate,,,,,,,,,2730,,,percent of total billed charges,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,2730,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,2730,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,2730,,,percent of total billed charges,,,,,,,,,2730,,,percent of total billed charges,,,1393.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2325.14,,,percent of total billed charges,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,2730,,,case rate,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,1638,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,2730,,,percent of total billed charges,,,2320.5,,,percent of total billed charges,,,,,,,,,,,,,,,2730,,,percent of total billed charges,,,1449.9,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1092,,,percent of total billed charges,,,5460,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,2730,,,percent of total billed charges,,,,,,,,,,,,,,,218.4,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,,,,,,,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,2730,,,case rate,,,2320.5,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,2730,,,case rate,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,2730,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1608.52,,,percent of total billed charges,,
R&B - PRIVATE,1140530110,CDM,110,RC,,,,,,,,inpatient,facility,,,1366.06,1366.06,109.28,8479.78,,1366.06,,,case rate,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,percent of total billed charges,,,697.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1163.47,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,819.64,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,1366.06,,,percent of total billed charges,,,1161.15,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,725.51,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,546.42,,,percent of total billed charges,,,2732.12,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,109.28,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,case rate,,,1161.15,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,683.03,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,804.88,,,percent of total billed charges,,
R&B - PRIVATE - TELEMETRY,1140530119,CDM,110,RC,,,,,,,,inpatient,facility,,,1706.74,1706.74,136.54,8479.78,,1706.74,,,case rate,,,,,,,,,1706.74,,,percent of total billed charges,,,1706.74,,,case rate,,,1706.74,,,case rate,,,,,,,,,1706.74,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3413.48,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,3413.48,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,3413.48,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,1706.74,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,1706.74,,,percent of total billed charges,,,,,,,,,1706.74,,,percent of total billed charges,,,871.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1453.63,,,percent of total billed charges,,,3413.48,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1706.74,,,case rate,,,1706.74,,,case rate,,,1706.74,,,case rate,,,,,,,,,1024.04,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,1706.74,,,percent of total billed charges,,,1450.73,,,percent of total billed charges,,,,,,,,,,,,,,,1706.74,,,percent of total billed charges,,,906.45,,,percent of total billed charges,,,1706.74,,,percent of total billed charges,,,1706.74,,,percent of total billed charges,,,3413.48,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,3413.48,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,3413.48,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,3413.48,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,3413.48,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,682.7,,,percent of total billed charges,,,3413.48,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",3413.48,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,3413.48,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1706.74,,,percent of total billed charges,,,,,,,,,,,,,,,136.54,,,percent of total billed charges,,,1706.74,,,percent of total billed charges,,,,,,,,,,,,,,,1706.74,,,percent of total billed charges,,,1706.74,,,percent of total billed charges,,,,,,,,,1706.74,,,case rate,,,1450.73,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1706.74,,,case rate,,,1706.74,,,case rate,,,1706.74,,,case rate,,,,,,,,,1706.74,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1706.74,,,percent of total billed charges,,,1706.74,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.37,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1005.61,,,percent of total billed charges,,
R&B PRIVATE ISOLATION,1140530164,CDM,164,RC,,,,,,,,inpatient,facility,,,2730,2730,218.4,8479.78,,2730,,,case rate,,,,,,,,,2730,,,percent of total billed charges,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,2730,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,2730,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,2730,,,percent of total billed charges,,,,,,,,,2730,,,percent of total billed charges,,,1393.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2325.14,,,percent of total billed charges,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,2730,,,case rate,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,1638,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,2730,,,percent of total billed charges,,,2320.5,,,percent of total billed charges,,,,,,,,,,,,,,,2730,,,percent of total billed charges,,,1449.9,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1092,,,percent of total billed charges,,,5460,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,2730,,,percent of total billed charges,,,,,,,,,,,,,,,218.4,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,,,,,,,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,2730,,,case rate,,,2320.5,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,2730,,,case rate,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,2730,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1608.52,,,percent of total billed charges,,
R&B ISOLATION TELEMETRY,1140530169,CDM,164,RC,,,,,,,,inpatient,facility,,,3549,3549,283.92,8479.78,,3549,,,case rate,,,,,,,,,3549,,,percent of total billed charges,,,3549,,,case rate,,,3549,,,case rate,,,,,,,,,3549,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,3549,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,3549,,,percent of total billed charges,,,,,,,,,3549,,,percent of total billed charges,,,1812.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3022.68,,,percent of total billed charges,,,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,3549,,,case rate,,,3549,,,case rate,,,3549,,,case rate,,,,,,,,,2129.4,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,3549,,,percent of total billed charges,,,3016.65,,,percent of total billed charges,,,,,,,,,,,,,,,3549,,,percent of total billed charges,,,1884.87,,,percent of total billed charges,,,3549,,,percent of total billed charges,,,3549,,,percent of total billed charges,,,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1419.6,,,percent of total billed charges,,,7098,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,3549,,,percent of total billed charges,,,,,,,,,,,,,,,283.92,,,percent of total billed charges,,,3549,,,percent of total billed charges,,,,,,,,,,,,,,,3549,,,percent of total billed charges,,,3549,,,percent of total billed charges,,,,,,,,,3549,,,case rate,,,3016.65,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,3549,,,case rate,,,3549,,,case rate,,,3549,,,case rate,,,,,,,,,3549,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3549,,,percent of total billed charges,,,3549,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1774.5,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2091.07,,,percent of total billed charges,,
R&B - PRIVATE,1140531110,CDM,110,RC,,,,,,,,inpatient,facility,,,1366.06,1366.06,109.28,8479.78,,1366.06,,,case rate,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,percent of total billed charges,,,697.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1163.47,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,819.64,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,1366.06,,,percent of total billed charges,,,1161.15,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,725.51,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,546.42,,,percent of total billed charges,,,2732.12,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,109.28,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,case rate,,,1161.15,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,683.03,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,804.88,,,percent of total billed charges,,
R&B - PRIVATE - TELEMETRY,1140531119,CDM,110,RC,,,,,,,,inpatient,facility,,,1707.58,1707.58,136.61,8479.78,,1707.58,,,case rate,,,,,,,,,1707.58,,,percent of total billed charges,,,1707.58,,,case rate,,,1707.58,,,case rate,,,,,,,,,1707.58,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3415.16,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,3415.16,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,3415.16,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,1707.58,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,1707.58,,,percent of total billed charges,,,,,,,,,1707.58,,,percent of total billed charges,,,871.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1454.35,,,percent of total billed charges,,,3415.16,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1707.58,,,case rate,,,1707.58,,,case rate,,,1707.58,,,case rate,,,,,,,,,1024.55,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,1707.58,,,percent of total billed charges,,,1451.44,,,percent of total billed charges,,,,,,,,,,,,,,,1707.58,,,percent of total billed charges,,,906.9,,,percent of total billed charges,,,1707.58,,,percent of total billed charges,,,1707.58,,,percent of total billed charges,,,3415.16,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,3415.16,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,3415.16,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,3415.16,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,3415.16,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,683.03,,,percent of total billed charges,,,3415.16,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",3415.16,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,3415.16,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1707.58,,,percent of total billed charges,,,,,,,,,,,,,,,136.61,,,percent of total billed charges,,,1707.58,,,percent of total billed charges,,,,,,,,,,,,,,,1707.58,,,percent of total billed charges,,,1707.58,,,percent of total billed charges,,,,,,,,,1707.58,,,case rate,,,1451.44,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1707.58,,,case rate,,,1707.58,,,case rate,,,1707.58,,,case rate,,,,,,,,,1707.58,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1707.58,,,percent of total billed charges,,,1707.58,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.79,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1006.11,,,percent of total billed charges,,
R&B - SEMIPRIVATE,1140531120,CDM,120,RC,,,,,,,,inpatient,facility,,,1366.06,1366.06,109.28,8479.78,,1366.06,,,case rate,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,percent of total billed charges,,,697.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1163.47,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,819.64,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,1366.06,,,percent of total billed charges,,,1161.15,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,725.51,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,546.42,,,percent of total billed charges,,,2732.12,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,109.28,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,case rate,,,1161.15,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,683.03,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,804.88,,,percent of total billed charges,,
R&B PRIVATE ISOLATION,1140531164,CDM,164,RC,,,,,,,,inpatient,facility,,,2730,2730,218.4,8479.78,,2730,,,case rate,,,,,,,,,2730,,,percent of total billed charges,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,2730,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,2730,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,2730,,,percent of total billed charges,,,,,,,,,2730,,,percent of total billed charges,,,1393.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2325.14,,,percent of total billed charges,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,2730,,,case rate,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,1638,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,2730,,,percent of total billed charges,,,2320.5,,,percent of total billed charges,,,,,,,,,,,,,,,2730,,,percent of total billed charges,,,1449.9,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1092,,,percent of total billed charges,,,5460,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,2730,,,percent of total billed charges,,,,,,,,,,,,,,,218.4,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,,,,,,,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,2730,,,case rate,,,2320.5,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,2730,,,case rate,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,2730,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1608.52,,,percent of total billed charges,,
R&B ISOLATION TELEMETRY,1140531169,CDM,164,RC,,,,,,,,inpatient,facility,,,3549,3549,283.92,8479.78,,3549,,,case rate,,,,,,,,,3549,,,percent of total billed charges,,,3549,,,case rate,,,3549,,,case rate,,,,,,,,,3549,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,3549,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,3549,,,percent of total billed charges,,,,,,,,,3549,,,percent of total billed charges,,,1812.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3022.68,,,percent of total billed charges,,,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,3549,,,case rate,,,3549,,,case rate,,,3549,,,case rate,,,,,,,,,2129.4,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,3549,,,percent of total billed charges,,,3016.65,,,percent of total billed charges,,,,,,,,,,,,,,,3549,,,percent of total billed charges,,,1884.87,,,percent of total billed charges,,,3549,,,percent of total billed charges,,,3549,,,percent of total billed charges,,,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1419.6,,,percent of total billed charges,,,7098,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,7098,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,3549,,,percent of total billed charges,,,,,,,,,,,,,,,283.92,,,percent of total billed charges,,,3549,,,percent of total billed charges,,,,,,,,,,,,,,,3549,,,percent of total billed charges,,,3549,,,percent of total billed charges,,,,,,,,,3549,,,case rate,,,3016.65,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,3549,,,case rate,,,3549,,,case rate,,,3549,,,case rate,,,,,,,,,3549,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3549,,,percent of total billed charges,,,3549,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1774.5,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2091.07,,,percent of total billed charges,,
R&B - PRIVATE,1140540110,CDM,110,RC,,,,,,,,inpatient,facility,,,1366.06,1366.06,109.28,8479.78,,1366.06,,,case rate,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,percent of total billed charges,,,697.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1163.47,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,819.64,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,1366.06,,,percent of total billed charges,,,1161.15,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,725.51,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,546.42,,,percent of total billed charges,,,2732.12,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,109.28,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,case rate,,,1161.15,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,683.03,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,804.88,,,percent of total billed charges,,
R&B - SEMIPRIVATE,1140540120,CDM,120,RC,,,,,,,,inpatient,facility,,,1366.06,1366.06,109.28,8479.78,,1366.06,,,case rate,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,percent of total billed charges,,,697.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1163.47,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,819.64,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,1366.06,,,percent of total billed charges,,,1161.15,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,725.51,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,546.42,,,percent of total billed charges,,,2732.12,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,109.28,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,case rate,,,1161.15,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,683.03,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,804.88,,,percent of total billed charges,,
R&B PRIVATE ISOLATION,1140540164,CDM,164,RC,,,,,,,,inpatient,facility,,,2730,2730,218.4,8479.78,,2730,,,case rate,,,,,,,,,2730,,,percent of total billed charges,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,2730,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,2730,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,2730,,,percent of total billed charges,,,,,,,,,2730,,,percent of total billed charges,,,1393.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2325.14,,,percent of total billed charges,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,2730,,,case rate,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,1638,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,2730,,,percent of total billed charges,,,2320.5,,,percent of total billed charges,,,,,,,,,,,,,,,2730,,,percent of total billed charges,,,1449.9,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1092,,,percent of total billed charges,,,5460,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,2730,,,percent of total billed charges,,,,,,,,,,,,,,,218.4,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,,,,,,,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,2730,,,case rate,,,2320.5,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,2730,,,case rate,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,2730,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1608.52,,,percent of total billed charges,,
R&B - PRIVATE,1140546110,CDM,110,RC,,,,,,,,inpatient,facility,,,1366.06,1366.06,109.28,8479.78,,1366.06,,,case rate,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,percent of total billed charges,,,697.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1163.47,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,819.64,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,1366.06,,,percent of total billed charges,,,1161.15,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,725.51,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,546.42,,,percent of total billed charges,,,2732.12,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,109.28,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,case rate,,,1161.15,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,683.03,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,804.88,,,percent of total billed charges,,
R&B PRIVATE ISOLATION,1140546164,CDM,164,RC,,,,,,,,inpatient,facility,,,2730,2730,218.4,8479.78,,2730,,,case rate,,,,,,,,,2730,,,percent of total billed charges,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,2730,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,2730,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,2730,,,percent of total billed charges,,,,,,,,,2730,,,percent of total billed charges,,,1393.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2325.14,,,percent of total billed charges,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,2730,,,case rate,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,1638,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,2730,,,percent of total billed charges,,,2320.5,,,percent of total billed charges,,,,,,,,,,,,,,,2730,,,percent of total billed charges,,,1449.9,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1092,,,percent of total billed charges,,,5460,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,2730,,,percent of total billed charges,,,,,,,,,,,,,,,218.4,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,,,,,,,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,2730,,,case rate,,,2320.5,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,2730,,,case rate,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,2730,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1608.52,,,percent of total billed charges,,
R&B - PRIVATE,1140550110,CDM,110,RC,,,,,,,,inpatient,facility,,,1366.06,1366.06,109.28,8479.78,,1366.06,,,case rate,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,percent of total billed charges,,,697.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1163.47,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,819.64,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,1366.06,,,percent of total billed charges,,,1161.15,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,725.51,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,546.42,,,percent of total billed charges,,,2732.12,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,109.28,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,case rate,,,1161.15,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,683.03,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,804.88,,,percent of total billed charges,,
R&B - SEMIPRIVATE,1140550120,CDM,120,RC,,,,,,,,inpatient,facility,,,1366.06,1366.06,109.28,8479.78,,1366.06,,,case rate,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,percent of total billed charges,,,697.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1163.47,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,819.64,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,1366.06,,,percent of total billed charges,,,1161.15,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,725.51,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,546.42,,,percent of total billed charges,,,2732.12,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,109.28,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,case rate,,,1161.15,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,683.03,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,804.88,,,percent of total billed charges,,
R&B PRIVATE ISOLATION,1140550164,CDM,164,RC,,,,,,,,inpatient,facility,,,2730,2730,218.4,8479.78,,2730,,,case rate,,,,,,,,,2730,,,percent of total billed charges,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,2730,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,2730,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,2730,,,percent of total billed charges,,,,,,,,,2730,,,percent of total billed charges,,,1393.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2325.14,,,percent of total billed charges,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,2730,,,case rate,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,1638,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,2730,,,percent of total billed charges,,,2320.5,,,percent of total billed charges,,,,,,,,,,,,,,,2730,,,percent of total billed charges,,,1449.9,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1092,,,percent of total billed charges,,,5460,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,5460,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,2730,,,percent of total billed charges,,,,,,,,,,,,,,,218.4,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,,,,,,,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,2730,,,case rate,,,2320.5,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,2730,,,case rate,,,2730,,,case rate,,,2730,,,case rate,,,,,,,,,2730,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2730,,,percent of total billed charges,,,2730,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1608.52,,,percent of total billed charges,,
R&B - PRIVATE,1142010110,CDM,110,RC,,,,,,,,inpatient,facility,,,1366.06,1366.06,109.28,8479.78,,1366.06,,,case rate,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,percent of total billed charges,,,697.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1163.47,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,819.64,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,1366.06,,,percent of total billed charges,,,1161.15,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,725.51,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,546.42,,,percent of total billed charges,,,2732.12,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,109.28,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,case rate,,,1161.15,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,683.03,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,804.88,,,percent of total billed charges,,
R&B - PRIVATE - PSYCH,1143000114,CDM,114,RC,,,,,,,,inpatient,facility,,,1313.52,1313.52,105.08,2627.04,,1683,,,per diem,,,,,,,,,1313.52,,,percent of total billed charges,,,1313.52,,,case rate,,,1313.52,,,case rate,,,,,,,,,1313.52,,,case rate,,,1046.28,,,per diem,,,900,,,per diem,,,960,,,per diem,,,804.83,,,per diem,,,,,,,,,2627.04,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.5100 ) ,other,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.5100 ) ,2627.04,,,per diem,,,2627.04,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.3424 ) ,other,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.3424 ) ,,,,,,,982.92,,,per diem,,,,,,,,,1016.05,,,per diem,,,883.52,,,per diem,,,,,,,,,1313.52,,,percent of total billed charges,,,,,,,,,1313.52,,,percent of total billed charges,,,670.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1118.72,,,percent of total billed charges,,,2627.04,,,per diem,,,,,,,,,1313.52,,,per diem,,,1313.52,,,per diem,,,1313.52,,,per diem,,,,,,,,,788.11,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,1313.52,,,percent of total billed charges,,,1116.49,,,percent of total billed charges,,,,,,,,,,,,,,,1313.52,,,percent of total billed charges,,,697.61,,,percent of total billed charges,,,1313.52,,,percent of total billed charges,,,1313.52,,,percent of total billed charges,,,2627.04,,,per diem,,,2627.04,,,per diem,,,954.59,,,per diem,,,,,,,,,,,,,,,2627.04,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2627.04,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2627.04,,,per diem,,,,,,,,,525.41,,,percent of total billed charges,,,2627.04,,,per diem,,,2627.04,,,per diem,,,2627.04,,,per diem,,,,,,,,,1313.52,,,percent of total billed charges,,,,,,,,,,,,,,,105.08,,,percent of total billed charges,,,1313.52,,,percent of total billed charges,,,,,,,,,,,,,,,1050,,,per diem,,,1313.52,,,percent of total billed charges,,,,,,,,,1313.52,,,per diem,,,1116.49,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1313.52,,,per diem,,,1313.52,,,per diem,,,1313.52,,,per diem,,,,,,,,,1313.52,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1313.52,,,percent of total billed charges,,,1313.52,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,656.76,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,773.93,,,percent of total billed charges,,
R&B - PRIVATE - PSYCH,1143020114,CDM,114,RC,,,,,,,,inpatient,facility,,,1313.52,1313.52,105.08,2627.04,,1683,,,per diem,,,,,,,,,1313.52,,,percent of total billed charges,,,1313.52,,,case rate,,,1313.52,,,case rate,,,,,,,,,1313.52,,,case rate,,,1046.28,,,per diem,,,900,,,per diem,,,960,,,per diem,,,804.83,,,per diem,,,,,,,,,2627.04,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.5100 ) ,other,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.5100 ) ,2627.04,,,per diem,,,2627.04,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.3424 ) ,other,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.3424 ) ,,,,,,,982.92,,,per diem,,,,,,,,,1016.05,,,per diem,,,883.52,,,per diem,,,,,,,,,1313.52,,,percent of total billed charges,,,,,,,,,1313.52,,,percent of total billed charges,,,670.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1118.72,,,percent of total billed charges,,,2627.04,,,per diem,,,,,,,,,1313.52,,,per diem,,,1313.52,,,per diem,,,1313.52,,,per diem,,,,,,,,,788.11,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,1313.52,,,percent of total billed charges,,,1116.49,,,percent of total billed charges,,,,,,,,,,,,,,,1313.52,,,percent of total billed charges,,,697.61,,,percent of total billed charges,,,1313.52,,,percent of total billed charges,,,1313.52,,,percent of total billed charges,,,2627.04,,,per diem,,,2627.04,,,per diem,,,954.59,,,per diem,,,,,,,,,,,,,,,2627.04,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2627.04,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2627.04,,,per diem,,,,,,,,,525.41,,,percent of total billed charges,,,2627.04,,,per diem,,,2627.04,,,per diem,,,2627.04,,,per diem,,,,,,,,,1313.52,,,percent of total billed charges,,,,,,,,,,,,,,,105.08,,,percent of total billed charges,,,1313.52,,,percent of total billed charges,,,,,,,,,,,,,,,1050,,,per diem,,,1313.52,,,percent of total billed charges,,,,,,,,,1313.52,,,per diem,,,1116.49,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1313.52,,,per diem,,,1313.52,,,per diem,,,1313.52,,,per diem,,,,,,,,,1313.52,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1313.52,,,percent of total billed charges,,,1313.52,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,656.76,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,773.93,,,percent of total billed charges,,
R&B - SEMIPRIVATE - PSYCH,1143020124,CDM,124,RC,,,,,,,,inpatient,facility,,,1366.06,1366.06,109.28,2732.12,,1683,,,per diem,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,,case rate,,,1046.28,,,per diem,,,900,,,per diem,,,960,,,per diem,,,804.83,,,per diem,,,,,,,,,2732.12,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.5100 ) ,other,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.5100 ) ,2732.12,,,per diem,,,2732.12,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.3424 ) ,other,,$954.59 Per Diem in the Service Type Formula:= ( Current Amount * 1.3424 ) ,,,,,,,982.92,,,per diem,,,,,,,,,1016.05,,,per diem,,,883.52,,,per diem,,,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,percent of total billed charges,,,697.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1163.47,,,percent of total billed charges,,,2732.12,,,per diem,,,,,,,,,1366.06,,,per diem,,,1366.06,,,per diem,,,1366.06,,,per diem,,,,,,,,,819.64,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,1366.06,,,percent of total billed charges,,,1161.15,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,725.51,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,2732.12,,,per diem,,,2732.12,,,per diem,,,954.59,,,per diem,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2732.12,,,per diem,,,,,,,,,546.42,,,percent of total billed charges,,,2732.12,,,per diem,,,2732.12,,,per diem,,,2732.12,,,per diem,,,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,109.28,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,1050,,,per diem,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,per diem,,,1161.15,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1366.06,,,per diem,,,1366.06,,,per diem,,,1366.06,,,per diem,,,,,,,,,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,683.03,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,804.88,,,percent of total billed charges,,
WEEKDAY ADMISSION DAY,1143020900,CDM,900,RC,,,,,,,,inpatient,facility,,,2975,2975,238,2975,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,,,,,,,2975,,,percent of total billed charges,,,1519.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2533.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1785,,,percent of total billed charges,,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,2528.75,,,percent of total billed charges,,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,1580.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1190,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,238,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1752.87,,,percent of total billed charges,,
WEEKDAY ADMISSION DAY,1143020900,CDM,900,RC,,,,,,,,outpatient,facility,,,2975,2975,238,2975,,2109.57,,,percent of total billed charges,,,725.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2975,,,percent of total billed charges,,,1864.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2091.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2091.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,2975,,,fee schedule,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1088.85,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2975,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2975,,,fee schedule,,,2975,,,percent of total billed charges,,,,,,,,,2975,,,percent of total billed charges,,,1823.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2119.69,,,percent of total billed charges,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,,1547,,,percent of total billed charges,,,1636.25,,,percent of total billed charges,,,,,,,,,1755.25,,,percent of total billed charges,,,548.68,,,per diem,,,2975,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2975,,,percent of total billed charges,,,2528.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1580.02,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2006.93,,,percent of total billed charges,,,2407.37,,,percent of total billed charges,,,,,,,,,,,,,,,1190,,,percent of total billed charges,,,,,,,,,1100.75,,,percent of total billed charges,,,1100.75,,,percent of total billed charges,,,,,,,,,2975,,,percent of total billed charges,,,2975,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2975,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,238,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,,,,,,,,,,,,,2975,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,,,,,,,2767.34,,,percent of total billed charges,,,,,,,,,,,,,,,2767.34,,,percent of total billed charges,,,2767.34,,,percent of total billed charges,,,2767.34,,,percent of total billed charges,,,2231.25,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,2975,,,percent of total billed charges,,,,,,,,,2085.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1487.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1752.87,,,percent of total billed charges,,
WEEKDAY ADMISSION DAY,1143020900,CDM,900,RC,999,EAPG,,,,,,outpatient,facility,,,2975,2975,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WEEKEND ADMISSION DAY,1143020919,CDM,919,RC,,,,,,,,inpatient,facility,,,3625,3625,290,3625,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,,,,,,,3625,,,percent of total billed charges,,,1850.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3087.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2175,,,percent of total billed charges,,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,3081.25,,,percent of total billed charges,,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,1925.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1450,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,290,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2135.85,,,percent of total billed charges,,
WEEKEND ADMISSION DAY,1143020919,CDM,919,RC,,,,,,,,outpatient,facility,,,3625,3625,290,3625,,2570.49,,,percent of total billed charges,,,884.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3625,,,percent of total billed charges,,,2271.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2548.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2548.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1326.75,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3625,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3625,,,fee schedule,,,3625,,,percent of total billed charges,,,,,,,,,3625,,,percent of total billed charges,,,2221.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2582.81,,,percent of total billed charges,,,,,,,,,,,,,,,1957.5,,,percent of total billed charges,,,1885,,,percent of total billed charges,,,1993.75,,,percent of total billed charges,,,,,,,,,2138.75,,,percent of total billed charges,,,548.68,,,per diem,,,3625,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3625,,,percent of total billed charges,,,3081.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1925.24,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2445.42,,,percent of total billed charges,,,2933.35,,,percent of total billed charges,,,,,,,,,,,,,,,1450,,,percent of total billed charges,,,,,,,,,1341.25,,,percent of total billed charges,,,1341.25,,,percent of total billed charges,,,,,,,,,3625,,,percent of total billed charges,,,3625,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3625,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,290,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,3625,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,,,,,,,3371.97,,,percent of total billed charges,,,,,,,,,,,,,,,3371.97,,,percent of total billed charges,,,3371.97,,,percent of total billed charges,,,3371.97,,,percent of total billed charges,,,2718.75,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,3625,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1812.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2135.85,,,percent of total billed charges,,
WEEKEND ADMISSION DAY,1143020919,CDM,919,RC,999,EAPG,,,,,,outpatient,facility,,,3625,3625,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
R&B ISOLATION TELEMETRY,1143760169,CDM,164,RC,,,,,,,,inpatient,facility,,,6158.88,6158.88,492.71,12317.76,,6158.88,,,case rate,,,,,,,,,6158.88,,,percent of total billed charges,,,6158.88,,,case rate,,,6158.88,,,case rate,,,,,,,,,6158.88,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,6158.88,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,6158.88,,,percent of total billed charges,,,,,,,,,6158.88,,,percent of total billed charges,,,3144.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5245.52,,,percent of total billed charges,,,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,6158.88,,,case rate,,,6158.88,,,case rate,,,6158.88,,,case rate,,,,,,,,,3695.33,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,6158.88,,,percent of total billed charges,,,5235.05,,,percent of total billed charges,,,,,,,,,,,,,,,6158.88,,,percent of total billed charges,,,3270.98,,,percent of total billed charges,,,6158.88,,,percent of total billed charges,,,6158.88,,,percent of total billed charges,,,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,2463.55,,,percent of total billed charges,,,12317.76,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,6158.88,,,percent of total billed charges,,,,,,,,,,,,,,,492.71,,,percent of total billed charges,,,6158.88,,,percent of total billed charges,,,,,,,,,,,,,,,6158.88,,,percent of total billed charges,,,6158.88,,,percent of total billed charges,,,,,,,,,6158.88,,,case rate,,,5235.05,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,6158.88,,,case rate,,,6158.88,,,case rate,,,6158.88,,,case rate,,,,,,,,,6158.88,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6158.88,,,percent of total billed charges,,,6158.88,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3079.44,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3628.81,,,percent of total billed charges,,
R&B ICU,1143760200,CDM,200,RC,,,,,,,,inpatient,facility,,,3455.71,3455.71,276.46,8479.78,,3455.71,,,case rate,,,,,,,,,3455.71,,,percent of total billed charges,,,3455.71,,,case rate,,,3455.71,,,case rate,,,,,,,,,3455.71,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6911.42,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,6911.42,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,6911.42,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,3455.71,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,3455.71,,,percent of total billed charges,,,,,,,,,3455.71,,,percent of total billed charges,,,1764.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2943.23,,,percent of total billed charges,,,6911.42,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,3455.71,,,case rate,,,3455.71,,,case rate,,,3455.71,,,case rate,,,,,,,,,2073.43,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,3455.71,,,percent of total billed charges,,,2937.35,,,percent of total billed charges,,,,,,,,,,,,,,,3455.71,,,percent of total billed charges,,,1835.33,,,percent of total billed charges,,,3455.71,,,percent of total billed charges,,,3455.71,,,percent of total billed charges,,,6911.42,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,6911.42,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,6911.42,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,6911.42,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,6911.42,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1382.28,,,percent of total billed charges,,,6911.42,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",6911.42,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,6911.42,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,3455.71,,,percent of total billed charges,,,,,,,,,,,,,,,276.46,,,percent of total billed charges,,,3455.71,,,percent of total billed charges,,,,,,,,,,,,,,,3455.71,,,percent of total billed charges,,,3455.71,,,percent of total billed charges,,,,,,,,,3455.71,,,case rate,,,2937.35,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,3455.71,,,case rate,,,3455.71,,,case rate,,,3455.71,,,case rate,,,,,,,,,3455.71,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3455.71,,,percent of total billed charges,,,3455.71,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1727.86,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2036.1,,,percent of total billed charges,,
R&B ICU/CCU ISOLATION,1143760209,CDM,200,RC,,,,,,,,inpatient,facility,,,6158.88,6158.88,492.71,12317.76,,6158.88,,,case rate,,,,,,,,,6158.88,,,percent of total billed charges,,,6158.88,,,case rate,,,6158.88,,,case rate,,,,,,,,,6158.88,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,6158.88,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,6158.88,,,percent of total billed charges,,,,,,,,,6158.88,,,percent of total billed charges,,,3144.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5245.52,,,percent of total billed charges,,,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,6158.88,,,case rate,,,6158.88,,,case rate,,,6158.88,,,case rate,,,,,,,,,3695.33,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,6158.88,,,percent of total billed charges,,,5235.05,,,percent of total billed charges,,,,,,,,,,,,,,,6158.88,,,percent of total billed charges,,,3270.98,,,percent of total billed charges,,,6158.88,,,percent of total billed charges,,,6158.88,,,percent of total billed charges,,,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,2463.55,,,percent of total billed charges,,,12317.76,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,12317.76,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,6158.88,,,percent of total billed charges,,,,,,,,,,,,,,,492.71,,,percent of total billed charges,,,6158.88,,,percent of total billed charges,,,,,,,,,,,,,,,6158.88,,,percent of total billed charges,,,6158.88,,,percent of total billed charges,,,,,,,,,6158.88,,,case rate,,,5235.05,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,6158.88,,,case rate,,,6158.88,,,case rate,,,6158.88,,,case rate,,,,,,,,,6158.88,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6158.88,,,percent of total billed charges,,,6158.88,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3079.44,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3628.81,,,percent of total billed charges,,
R&B - SEMIPRIVATE,1150150120,CDM,120,RC,,,,,,,,inpatient,facility,,,1366.06,1366.06,109.28,8479.78,,1366.06,,,case rate,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,percent of total billed charges,,,697.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1163.47,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,819.64,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,1366.06,,,percent of total billed charges,,,1161.15,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,725.51,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,546.42,,,percent of total billed charges,,,2732.12,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,2732.12,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,109.28,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,,,,,,,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,1366.06,,,case rate,,,1161.15,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,1366.06,,,case rate,,,1366.06,,,case rate,,,1366.06,,,case rate,,,,,,,,,1366.06,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1366.06,,,percent of total billed charges,,,1366.06,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,683.03,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,804.88,,,percent of total billed charges,,
R&B ICU,1150150200,CDM,200,RC,,,,,,,,inpatient,facility,,,3322.8,3322.8,265.82,8479.78,,3322.8,,,case rate,,,,,,,,,3322.8,,,percent of total billed charges,,,3322.8,,,case rate,,,3322.8,,,case rate,,,,,,,,,3322.8,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6645.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,6645.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,6645.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,,,,,,,8479.78,,,case rate,,,,,,,,,,,,,,service not payable,3322.8,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,,,,,,,3322.8,,,percent of total billed charges,,,,,,,,,3322.8,,,percent of total billed charges,,,1696.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2830.03,,,percent of total billed charges,,,6645.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,3322.8,,,case rate,,,3322.8,,,case rate,,,3322.8,,,case rate,,,,,,,,,1993.68,,,percent of total billed charges,,,,,,,,,530.95,,,per diem,,,3322.8,,,percent of total billed charges,,,2824.38,,,percent of total billed charges,,,,,,,,,,,,,,,3322.8,,,percent of total billed charges,,,1764.74,,,percent of total billed charges,,,3322.8,,,percent of total billed charges,,,3322.8,,,percent of total billed charges,,,6645.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 11982.76 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment1   Formula:= ( 1.00000   ) ,6645.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 12237.16  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,service not payable,,,,,,,,,,,,,6645.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 19947.69  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,6645.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [NHP QHP V38] * 20631.49  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 45000.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4453 ) ,6645.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   Group (Sum Of):  Is:    DRG: [MA MCD DRG] * 11982.76  Plus:    $0.00 Flat Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 42430.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4531 ) Interim Value: PPR Adjustment   Formula:= ( 1.00000   ) ,,,,,,,1329.12,,,percent of total billed charges,,,6645.6,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",other,,"Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 12237.16 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40,963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ",6645.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 28111.70 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,6645.6,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,other,,Note: This service type is in place to establish values for   reimbursement. Interim Value: APAD   DRG: [MA MCD DRG] * 15186.40 Interim Value: Discharge Outlier Threshold   Formula:= ( APAD + 40963.00 ) Interim Value: Discharge Case Cost   Formula:= ( Gross Charges * 0.4243 ) Interim Value: PPR Adjustment   Formula:= ( 1.0000   ) ,,,,,,,3322.8,,,percent of total billed charges,,,,,,,,,,,,,,,265.82,,,percent of total billed charges,,,3322.8,,,percent of total billed charges,,,,,,,,,,,,,,,3322.8,,,percent of total billed charges,,,3322.8,,,percent of total billed charges,,,,,,,,,3322.8,,,case rate,,,2824.38,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 220020   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%  Ignore PAI date requirement   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100%   Apply sequestration reduction If ( Current Amount = 0 )   Then:  85.00 % of Gross Charges ,,,,,,,3322.8,,,case rate,,,3322.8,,,case rate,,,3322.8,,,case rate,,,,,,,,,3322.8,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3322.8,,,percent of total billed charges,,,3322.8,,,percent of total billed charges,,,,,,,,,2688,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1661.4,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1957.79,,,percent of total billed charges,,
KEDRAB 300 UNITS/2 ML INJ,2500000007,CDM,636,RC,90377,CPT,4928119020,NDC,,,,inpatient,facility,2,ML,2986.93,2986.93,238.95,2986.93,,,,,,,,,,,,,,2986.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2986.93,,,percent of total billed charges,,,,,,,,,2986.93,,,percent of total billed charges,,,1525.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2543.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1792.16,,,percent of total billed charges,,,,,,,,,,,,,,,2986.93,,,percent of total billed charges,,,2538.89,,,percent of total billed charges,,,,,,,,,,,,,,,2986.93,,,percent of total billed charges,,,1586.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1194.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2986.93,,,percent of total billed charges,,,,,,,,,,,,,,,238.95,,,percent of total billed charges,,,2986.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2986.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1759.9,,,percent of total billed charges,,
KEDRAB 300 UNITS/2 ML INJ,2500000007,CDM,636,RC,90377,CPT,4928119020,NDC,,,,outpatient,facility,2,ML,2986.93,2986.93,160.84,2986.93,,2118.03,,,percent of total billed charges,,,,,,,,,2986.93,,,percent of total billed charges,,,338.05,,,fee schedule,,,319.82,,,fee schedule,,,,,,,,,319.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2986.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2986.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2986.93,,,fee schedule,,,2986.93,,,percent of total billed charges,,,,,,,,,2986.93,,,percent of total billed charges,,,1830.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2128.19,,,percent of total billed charges,,,,,,,,,,,,,,,256.31,,,fee schedule,,,256.31,,,fee schedule,,,256.31,,,fee schedule,,,,,,,,,1762.29,,,percent of total billed charges,,,548.68,,,per diem,,,2986.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2986.93,,,percent of total billed charges,,,2538.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1586.36,,,percent of total billed charges,,,2986.93,,,percent of total billed charges,,,2986.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2014.98,,,percent of total billed charges,,,2417.02,,,percent of total billed charges,,,,,,,,,,,,,,,1194.77,,,percent of total billed charges,,,,,,,,,579.02,,,fee schedule,,,416.65,,,fee schedule,,,,,,,,,2986.93,,,percent of total billed charges,,,,,,,,,,,,,,,238.95,,,percent of total billed charges,,,2986.93,,,percent of total billed charges,,,,,,,,,,,,,,,2986.93,,,percent of total billed charges,,,2986.93,,,percent of total billed charges,,,,,,,,,247.44,,,fee schedule,,,,,,,,,,,,,,,214.46,,,fee schedule,,,285.95,,,fee schedule,,,160.84,,,fee schedule,,,270.26,,,fee schedule,,,2986.93,,,percent of total billed charges,,,2986.93,,,percent of total billed charges,,,2986.93,,,percent of total billed charges,,,,,,,,,2094.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1493.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1759.9,,,percent of total billed charges,,
KEDRAB 300 UNITS/2 ML INJ,2500000007,CDM,636,RC,90377,CPT,4928119020,NDC,9201,APC,,outpatient,facility,2,ML,2986.93,2986.93,240.5,1093.22,,,,,,,,258.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,250.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.03,,,fee schedule,,,,,,,,,1093.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,250.52,,,fee schedule,,,,,,,,,,,,,,,263.05,,,fee schedule,,,263.05,,,fee schedule,,,,,,,,,250.52,,,fee schedule,,,250.52,,,fee schedule,,,263.05,,,fee schedule,,,,,,,,,,,,,,,375.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,250.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.5,,,fee schedule,,,268.06,,,fee schedule,,,263.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.52,,,fee schedule,,,250.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,260.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,250.52,,,fee schedule,,,,,,,,,313.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,313.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,250.52,,,fee schedule,,,250.52,,,fee schedule,,,,,,,,,,,,,,,250.52,,,fee schedule,,,,,,,,,250.52,,,fee schedule,,,258.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.52,,,fee schedule,,,,,,,,,,,,,,,260.54,,,fee schedule,,,250.52,,,fee schedule,,,,,,,,,250.52,,,fee schedule,,,,,,,,,250.52,,,fee schedule,,,263.05,,,fee schedule,,,,,,,,
KEDRAB 300 UNITS/2 ML INJ,2500000007,CDM,636,RC,90377,CPT,4928119020,NDC,999,EAPG,,outpatient,facility,2,ML,2986.93,2986.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KEDRAB 1500 UNITS/10 ML INJ,2500000009,CDM,636,RC,90377,CPT,7612515010,NDC,,,,inpatient,facility,10,ML,11230.69,11230.69,898.46,11230.69,,,,,,,,,,,,,,11230.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11230.69,,,percent of total billed charges,,,,,,,,,11230.69,,,percent of total billed charges,,,5734.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9565.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6738.41,,,percent of total billed charges,,,,,,,,,,,,,,,11230.69,,,percent of total billed charges,,,9546.09,,,percent of total billed charges,,,,,,,,,,,,,,,11230.69,,,percent of total billed charges,,,5964.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4492.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11230.69,,,percent of total billed charges,,,,,,,,,,,,,,,898.46,,,percent of total billed charges,,,11230.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11230.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6617.12,,,percent of total billed charges,,
KEDRAB 1500 UNITS/10 ML INJ,2500000009,CDM,636,RC,90377,CPT,7612515010,NDC,,,,outpatient,facility,10,ML,11230.69,11230.69,160.84,11230.69,,7963.68,,,percent of total billed charges,,,,,,,,,11230.69,,,percent of total billed charges,,,338.05,,,fee schedule,,,319.82,,,fee schedule,,,,,,,,,319.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,11230.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11230.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,11230.69,,,fee schedule,,,11230.69,,,percent of total billed charges,,,,,,,,,11230.69,,,percent of total billed charges,,,6883.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8001.87,,,percent of total billed charges,,,,,,,,,,,,,,,256.31,,,fee schedule,,,256.31,,,fee schedule,,,256.31,,,fee schedule,,,,,,,,,6626.11,,,percent of total billed charges,,,548.68,,,per diem,,,11230.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11230.69,,,percent of total billed charges,,,9546.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5964.62,,,percent of total billed charges,,,11230.69,,,percent of total billed charges,,,11230.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7576.22,,,percent of total billed charges,,,9087.87,,,percent of total billed charges,,,,,,,,,,,,,,,4492.28,,,percent of total billed charges,,,,,,,,,579.02,,,fee schedule,,,416.65,,,fee schedule,,,,,,,,,11230.69,,,percent of total billed charges,,,,,,,,,,,,,,,898.46,,,percent of total billed charges,,,11230.69,,,percent of total billed charges,,,,,,,,,,,,,,,11230.69,,,percent of total billed charges,,,11230.69,,,percent of total billed charges,,,,,,,,,247.44,,,fee schedule,,,,,,,,,,,,,,,214.46,,,fee schedule,,,285.95,,,fee schedule,,,160.84,,,fee schedule,,,270.26,,,fee schedule,,,11230.69,,,percent of total billed charges,,,11230.69,,,percent of total billed charges,,,11230.69,,,percent of total billed charges,,,,,,,,,7873.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5615.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6617.12,,,percent of total billed charges,,
KEDRAB 1500 UNITS/10 ML INJ,2500000009,CDM,636,RC,90377,CPT,7612515010,NDC,9201,APC,,outpatient,facility,10,ML,11230.69,11230.69,240.5,4110.43,,,,,,,,258.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,250.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.03,,,fee schedule,,,,,,,,,4110.43,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,250.52,,,fee schedule,,,,,,,,,,,,,,,263.05,,,fee schedule,,,263.05,,,fee schedule,,,,,,,,,250.52,,,fee schedule,,,250.52,,,fee schedule,,,263.05,,,fee schedule,,,,,,,,,,,,,,,375.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,250.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.5,,,fee schedule,,,268.06,,,fee schedule,,,263.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.52,,,fee schedule,,,250.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,260.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,250.52,,,fee schedule,,,,,,,,,313.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,313.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,250.52,,,fee schedule,,,250.52,,,fee schedule,,,,,,,,,,,,,,,250.52,,,fee schedule,,,,,,,,,250.52,,,fee schedule,,,258.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.52,,,fee schedule,,,,,,,,,,,,,,,260.54,,,fee schedule,,,250.52,,,fee schedule,,,,,,,,,250.52,,,fee schedule,,,,,,,,,250.52,,,fee schedule,,,263.05,,,fee schedule,,,,,,,,
KEDRAB 1500 UNITS/10 ML INJ,2500000009,CDM,636,RC,90377,CPT,7612515010,NDC,999,EAPG,,outpatient,facility,10,ML,11230.69,11230.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEP B VAC 20 MCG/ 1 ML INJ,2500000235,CDM,636,RC,90746,CPT,5816082111,NDC,,,,inpatient,facility,1,UN,226.84,226.84,18.15,226.84,,,,,,,,,,,,,,226.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.84,,,percent of total billed charges,,,,,,,,,226.84,,,percent of total billed charges,,,115.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.1,,,percent of total billed charges,,,,,,,,,,,,,,,226.84,,,percent of total billed charges,,,192.81,,,percent of total billed charges,,,,,,,,,,,,,,,226.84,,,percent of total billed charges,,,120.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,226.84,,,percent of total billed charges,,,,,,,,,,,,,,,18.15,,,percent of total billed charges,,,226.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,226.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.65,,,percent of total billed charges,,
HEP B VAC 20 MCG/ 1 ML INJ,2500000235,CDM,636,RC,90746,CPT,5816082111,NDC,,,,outpatient,facility,1,UN,226.84,226.84,18.15,548.68,,160.85,,,percent of total billed charges,,,43.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,226.84,,,percent of total billed charges,,,91.35,,,fee schedule,,,86.43,,,fee schedule,,,42.24,,,fee schedule,,,86.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,226.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,42.66,,,fee schedule,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,83.02,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,68.07,,,fee schedule,,,70.38,,,fee schedule,,,226.84,,,percent of total billed charges,,,42.24,,,fee schedule,,,226.84,,,percent of total billed charges,,,139.03,,,percent of total billed charges,,,44.35,,,fee schedule,,,44.35,,,fee schedule,,,,,,,,,43.1,,,fee schedule,,,42.24,,,fee schedule,,,44.35,,,fee schedule,,,161.62,,,percent of total billed charges,,,,,,,,,63.36,,,fee schedule,,,76.04,,,fee schedule,,,76.04,,,fee schedule,,,76.04,,,fee schedule,,,43.5,,,fee schedule,,,133.84,,,percent of total billed charges,,,548.68,,,per diem,,,226.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,226.84,,,percent of total billed charges,,,192.81,,,percent of total billed charges,,,40.76,,,fee schedule,,,45.2,,,fee schedule,,,45.26,,,fee schedule,,,120.47,,,percent of total billed charges,,,226.84,,,percent of total billed charges,,,226.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,42.24,,,fee schedule,,,42.24,,,fee schedule,,,153.03,,,percent of total billed charges,,,183.56,,,percent of total billed charges,,,,,,,,,44.82,,,fee schedule,,,90.74,,,percent of total billed charges,,,,,,,,,172.92,,,fee schedule,,,124.43,,,fee schedule,,,42.24,,,fee schedule,,,226.84,,,percent of total billed charges,,,52.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,52.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.15,,,percent of total billed charges,,,226.84,,,percent of total billed charges,,,42.24,,,fee schedule,,,63.36,,,fee schedule,,,226.84,,,percent of total billed charges,,,226.84,,,percent of total billed charges,,,42.24,,,fee schedule,,,73.9,,,fee schedule,,,42.24,,,fee schedule,,,43.51,,,fee schedule,,,64.05,,,fee schedule,,,85.4,,,fee schedule,,,48.04,,,fee schedule,,,73.03,,,fee schedule,,,226.84,,,percent of total billed charges,,,226.84,,,percent of total billed charges,,,226.84,,,percent of total billed charges,,,111.76,,,fee schedule,,,159.04,,,percent of total billed charges,,,42.24,,,fee schedule,,,45.04,,,fee schedule,,,42.24,,,fee schedule,,,51.12,,,fee schedule,,,43.1,,,fee schedule,,,113.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,43.1,,,fee schedule,,,44.35,,,fee schedule,,,,,,,,service not payable
HEP B VAC 20 MCG/ 1 ML INJ,2500000235,CDM,636,RC,90746,CPT,5816082111,NDC,414,EAPG,,outpatient,facility,1,UN,226.84,226.84,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PNEUMOCOC VAC 23 VALENT >2 YRS,2500000240,CDM,636,RC,90732,CPT,6494300,NDC,,,,inpatient,facility,0.5,UN,386.36,386.36,30.91,386.36,,,,,,,,,,,,,,386.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.36,,,percent of total billed charges,,,,,,,,,386.36,,,percent of total billed charges,,,197.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,329.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.82,,,percent of total billed charges,,,,,,,,,,,,,,,386.36,,,percent of total billed charges,,,328.41,,,percent of total billed charges,,,,,,,,,,,,,,,386.36,,,percent of total billed charges,,,205.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,386.36,,,percent of total billed charges,,,,,,,,,,,,,,,30.91,,,percent of total billed charges,,,386.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,386.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.64,,,percent of total billed charges,,
PNEUMOCOC VAC 23 VALENT >2 YRS,2500000240,CDM,636,RC,90732,CPT,6494300,NDC,,,,outpatient,facility,0.5,UN,386.36,386.36,30.91,548.68,,273.97,,,percent of total billed charges,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,386.36,,,percent of total billed charges,,,173.24,,,fee schedule,,,163.9,,,fee schedule,,,71.94,,,fee schedule,,,163.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,386.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.66,,,fee schedule,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,141.41,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,49.3,,,fee schedule,,,133.47,,,fee schedule,,,386.36,,,percent of total billed charges,,,71.94,,,fee schedule,,,386.36,,,percent of total billed charges,,,236.8,,,percent of total billed charges,,,75.54,,,fee schedule,,,75.54,,,fee schedule,,,,,,,,,73.41,,,fee schedule,,,71.94,,,fee schedule,,,75.54,,,fee schedule,,,275.28,,,percent of total billed charges,,,,,,,,,107.91,,,fee schedule,,,133.48,,,fee schedule,,,133.48,,,fee schedule,,,133.48,,,fee schedule,,,74.1,,,fee schedule,,,227.95,,,percent of total billed charges,,,548.68,,,per diem,,,386.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,386.36,,,percent of total billed charges,,,328.41,,,percent of total billed charges,,,69.42,,,fee schedule,,,76.98,,,fee schedule,,,77.08,,,fee schedule,,,205.2,,,percent of total billed charges,,,386.36,,,percent of total billed charges,,,386.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.94,,,fee schedule,,,71.94,,,fee schedule,,,260.64,,,percent of total billed charges,,,312.64,,,percent of total billed charges,,,,,,,,,76.35,,,fee schedule,,,154.54,,,percent of total billed charges,,,,,,,,,327.94,,,fee schedule,,,235.97,,,fee schedule,,,71.94,,,fee schedule,,,386.36,,,percent of total billed charges,,,89.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,89.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.91,,,percent of total billed charges,,,386.36,,,percent of total billed charges,,,71.94,,,fee schedule,,,107.92,,,fee schedule,,,386.36,,,percent of total billed charges,,,386.36,,,percent of total billed charges,,,71.94,,,fee schedule,,,140.14,,,fee schedule,,,71.94,,,fee schedule,,,74.1,,,fee schedule,,,121.46,,,fee schedule,,,161.95,,,fee schedule,,,91.09,,,fee schedule,,,138.51,,,fee schedule,,,386.36,,,percent of total billed charges,,,386.36,,,percent of total billed charges,,,386.36,,,percent of total billed charges,,,126.45,,,fee schedule,,,270.88,,,percent of total billed charges,,,71.94,,,fee schedule,,,76.71,,,fee schedule,,,71.94,,,fee schedule,,,77.28,,,fee schedule,,,73.41,,,fee schedule,,,193.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,73.41,,,fee schedule,,,75.54,,,fee schedule,,,227.64,,,percent of total billed charges,,
PNEUMOCOC VAC 23 VALENT >2 YRS,2500000240,CDM,636,RC,90732,CPT,6494300,NDC,414,EAPG,,outpatient,facility,0.5,UN,386.36,386.36,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MUMPS MEASLE RUBELLA VACCINE,2500000250,CDM,636,RC,90707,CPT,,,,,,inpatient,facility,0.5,UN,280.7,280.7,22.46,280.7,,,,,,,,,,,,,,280.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.7,,,percent of total billed charges,,,,,,,,,280.7,,,percent of total billed charges,,,143.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.42,,,percent of total billed charges,,,,,,,,,,,,,,,280.7,,,percent of total billed charges,,,238.59,,,percent of total billed charges,,,,,,,,,,,,,,,280.7,,,percent of total billed charges,,,149.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,280.7,,,percent of total billed charges,,,,,,,,,,,,,,,22.46,,,percent of total billed charges,,,280.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,280.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.39,,,percent of total billed charges,,
MUMPS MEASLE RUBELLA VACCINE,2500000250,CDM,636,RC,90707,CPT,,,,,,outpatient,facility,0.5,UN,280.7,280.7,22.46,548.68,,199.04,,,percent of total billed charges,,,68.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,280.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,280.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,102.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,53.66,,,fee schedule,,,280.7,,,fee schedule,,,280.7,,,percent of total billed charges,,,,,,,,,280.7,,,percent of total billed charges,,,172.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,165.61,,,percent of total billed charges,,,548.68,,,per diem,,,280.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,280.7,,,percent of total billed charges,,,238.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,149.08,,,percent of total billed charges,,,280.7,,,percent of total billed charges,,,280.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.36,,,percent of total billed charges,,,227.14,,,percent of total billed charges,,,,,,,,,,,,,,,112.28,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,280.7,,,percent of total billed charges,,,280.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,280.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.46,,,percent of total billed charges,,,280.7,,,percent of total billed charges,,,,,,,,,,,,,,,280.7,,,percent of total billed charges,,,280.7,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,54.47,,,fee schedule,,,280.7,,,percent of total billed charges,,,280.7,,,percent of total billed charges,,,280.7,,,percent of total billed charges,,,,,,,,,196.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,165.39,,,percent of total billed charges,,
MUMPS MEASLE RUBELLA VACCINE,2500000250,CDM,636,RC,90707,CPT,414,EAPG,,,,outpatient,facility,0.5,UN,280.7,280.7,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TETANUS IMMUNE GLOB INJ 250 U,2500000320,CDM,636,RC,J1670,HCPCS,1353363402,NDC,,,,inpatient,facility,250,UN,2313.5,2313.5,185.08,2313.5,,,,,,,,,,,,,,2313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2313.5,,,percent of total billed charges,,,,,,,,,2313.5,,,percent of total billed charges,,,1181.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1970.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1388.1,,,percent of total billed charges,,,,,,,,,,,,,,,2313.5,,,percent of total billed charges,,,1966.48,,,percent of total billed charges,,,,,,,,,,,,,,,2313.5,,,percent of total billed charges,,,1228.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,925.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2313.5,,,percent of total billed charges,,,,,,,,,,,,,,,185.08,,,percent of total billed charges,,,2313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1363.11,,,percent of total billed charges,,
TETANUS IMMUNE GLOB INJ 250 U,2500000320,CDM,636,RC,J1670,HCPCS,1353363402,NDC,,,,outpatient,facility,250,UN,2313.5,2313.5,185.08,2313.5,,1640.5,,,percent of total billed charges,,,,,,,,,2313.5,,,percent of total billed charges,,,733.27,,,fee schedule,,,693.72,,,fee schedule,,,,,,,,,693.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,293.65,,,fee schedule,,,2313.5,,,fee schedule,,,2313.5,,,percent of total billed charges,,,,,,,,,2313.5,,,percent of total billed charges,,,1417.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1648.37,,,percent of total billed charges,,,,,,,,,,,,,,,578.61,,,fee schedule,,,578.61,,,fee schedule,,,578.61,,,fee schedule,,,,,,,,,1364.96,,,percent of total billed charges,,,548.68,,,per diem,,,2313.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2313.5,,,percent of total billed charges,,,1966.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1228.7,,,percent of total billed charges,,,2313.5,,,percent of total billed charges,,,2313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1560.69,,,percent of total billed charges,,,1872.08,,,percent of total billed charges,,,,,,,,,,,,,,,925.4,,,percent of total billed charges,,,,,,,,,1321.3,,,fee schedule,,,950.78,,,fee schedule,,,,,,,,,2313.5,,,percent of total billed charges,,,,,,,,,,,,,,,185.08,,,percent of total billed charges,,,2313.5,,,percent of total billed charges,,,,,,,,,,,,,,,2313.5,,,percent of total billed charges,,,2313.5,,,percent of total billed charges,,,,,,,,,564.66,,,fee schedule,,,,,,,,,,,,,,,489.4,,,fee schedule,,,652.53,,,fee schedule,,,367.03,,,fee schedule,,,586.23,,,fee schedule,,,2313.5,,,percent of total billed charges,,,2313.5,,,percent of total billed charges,,,2313.5,,,percent of total billed charges,,,,,,,,,1621.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1363.11,,,percent of total billed charges,,
TETANUS IMMUNE GLOB INJ 250 U,2500000320,CDM,636,RC,J1670,HCPCS,1353363402,NDC,1670,APC,,outpatient,facility,250,UN,2313.5,2313.5,549.19,858.1,,,,,,,,589.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,572.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.79,,,fee schedule,,,,,,,,,846.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,572.07,,,fee schedule,,,,,,,,,,,,,,,600.67,,,fee schedule,,,600.67,,,fee schedule,,,,,,,,,572.07,,,fee schedule,,,572.07,,,fee schedule,,,600.67,,,fee schedule,,,,,,,,,,,,,,,858.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,572.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,549.19,,,fee schedule,,,612.11,,,fee schedule,,,600.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,572.07,,,fee schedule,,,572.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,594.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,572.07,,,fee schedule,,,,,,,,,715.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,715.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,572.07,,,fee schedule,,,572.07,,,fee schedule,,,,,,,,,,,,,,,572.07,,,fee schedule,,,,,,,,,572.07,,,fee schedule,,,589.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,572.07,,,fee schedule,,,,,,,,,,,,,,,594.95,,,fee schedule,,,572.07,,,fee schedule,,,,,,,,,572.07,,,fee schedule,,,,,,,,,572.07,,,fee schedule,,,600.67,,,fee schedule,,,,,,,,
TETANUS IMMUNE GLOB INJ 250 U,2500000320,CDM,636,RC,J1670,HCPCS,1353363402,NDC,438,EAPG,,outpatient,facility,250,UN,2313.5,2313.5,332.92,502.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,502.71,,,fee schedule,,,332.92,,,fee schedule,,,446.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INFLUENZA VAC FLUZONE HD 65Y,2500000335,CDM,636,RC,90662,CPT,,,,,,inpatient,facility,1,UN,210.41,210.41,16.83,210.41,,,,,,,,,,,,,,210.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210.41,,,percent of total billed charges,,,,,,,,,210.41,,,percent of total billed charges,,,107.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.25,,,percent of total billed charges,,,,,,,,,,,,,,,210.41,,,percent of total billed charges,,,178.85,,,percent of total billed charges,,,,,,,,,,,,,,,210.41,,,percent of total billed charges,,,111.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,210.41,,,percent of total billed charges,,,,,,,,,,,,,,,16.83,,,percent of total billed charges,,,210.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.97,,,percent of total billed charges,,
INFLUENZA VAC FLUZONE HD 65Y,2500000335,CDM,636,RC,90662,CPT,,,,,,outpatient,facility,1,UN,210.41,210.41,16.83,548.68,,149.2,,,percent of total billed charges,,,40.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,210.41,,,percent of total billed charges,,,95.27,,,fee schedule,,,90.14,,,fee schedule,,,39.18,,,fee schedule,,,90.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,210.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.57,,,fee schedule,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,77.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,83.49,,,fee schedule,,,210.41,,,percent of total billed charges,,,39.18,,,fee schedule,,,210.41,,,percent of total billed charges,,,128.96,,,percent of total billed charges,,,41.14,,,fee schedule,,,41.14,,,fee schedule,,,,,,,,,39.98,,,fee schedule,,,39.18,,,fee schedule,,,41.14,,,fee schedule,,,149.92,,,percent of total billed charges,,,,,,,,,58.77,,,fee schedule,,,73.4,,,fee schedule,,,73.4,,,fee schedule,,,73.4,,,fee schedule,,,40.36,,,fee schedule,,,124.14,,,percent of total billed charges,,,548.68,,,per diem,,,210.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,210.41,,,percent of total billed charges,,,178.85,,,percent of total billed charges,,,37.81,,,fee schedule,,,41.92,,,fee schedule,,,41.98,,,fee schedule,,,111.75,,,percent of total billed charges,,,210.41,,,percent of total billed charges,,,210.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.18,,,fee schedule,,,39.18,,,fee schedule,,,141.94,,,percent of total billed charges,,,170.26,,,percent of total billed charges,,,,,,,,,41.58,,,fee schedule,,,84.16,,,percent of total billed charges,,,,,,,,,171.84,,,fee schedule,,,123.65,,,fee schedule,,,39.18,,,fee schedule,,,210.41,,,percent of total billed charges,,,48.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,48.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.83,,,percent of total billed charges,,,210.41,,,percent of total billed charges,,,39.18,,,fee schedule,,,58.77,,,fee schedule,,,210.41,,,percent of total billed charges,,,210.41,,,percent of total billed charges,,,39.18,,,fee schedule,,,73.44,,,fee schedule,,,39.18,,,fee schedule,,,40.36,,,fee schedule,,,63.65,,,fee schedule,,,84.87,,,fee schedule,,,47.74,,,fee schedule,,,76.18,,,fee schedule,,,210.41,,,percent of total billed charges,,,210.41,,,percent of total billed charges,,,210.41,,,percent of total billed charges,,,66.27,,,fee schedule,,,147.52,,,percent of total billed charges,,,39.18,,,fee schedule,,,41.78,,,fee schedule,,,39.18,,,fee schedule,,,39.18,,,fee schedule,,,39.98,,,fee schedule,,,105.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,39.98,,,fee schedule,,,41.14,,,fee schedule,,,123.97,,,percent of total billed charges,,
INFLUENZA VAC FLUZONE HD 65Y,2500000335,CDM,636,RC,90662,CPT,414,EAPG,,,,outpatient,facility,1,UN,210.41,210.41,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RABIES VACCINE 2.5 IU SYR IM,2500000341,CDM,636,RC,90675,CPT,5816096412,NDC,,,,inpatient,facility,1,UN,1311.07,1311.07,104.89,1311.07,,,,,,,,,,,,,,1311.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1311.07,,,percent of total billed charges,,,,,,,,,1311.07,,,percent of total billed charges,,,669.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.64,,,percent of total billed charges,,,,,,,,,,,,,,,1311.07,,,percent of total billed charges,,,1114.41,,,percent of total billed charges,,,,,,,,,,,,,,,1311.07,,,percent of total billed charges,,,696.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,524.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1311.07,,,percent of total billed charges,,,,,,,,,,,,,,,104.89,,,percent of total billed charges,,,1311.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1311.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,772.48,,,percent of total billed charges,,
RABIES VACCINE 2.5 IU SYR IM,2500000341,CDM,636,RC,90675,CPT,5816096412,NDC,,,,outpatient,facility,1,UN,1311.07,1311.07,104.89,1311.07,,929.68,,,percent of total billed charges,,,,,,,,,1311.07,,,percent of total billed charges,,,439.36,,,fee schedule,,,415.67,,,fee schedule,,,,,,,,,415.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1311.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,206.65,,,fee schedule,,,1311.07,,,fee schedule,,,1311.07,,,percent of total billed charges,,,,,,,,,1311.07,,,percent of total billed charges,,,803.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,934.14,,,percent of total billed charges,,,,,,,,,,,,,,,324.74,,,fee schedule,,,324.74,,,fee schedule,,,324.74,,,fee schedule,,,,,,,,,773.53,,,percent of total billed charges,,,548.68,,,per diem,,,1311.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1311.07,,,percent of total billed charges,,,1114.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,696.31,,,percent of total billed charges,,,1311.07,,,percent of total billed charges,,,1311.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,884.45,,,percent of total billed charges,,,1060.92,,,percent of total billed charges,,,,,,,,,,,,,,,524.43,,,percent of total billed charges,,,,,,,,,856.34,,,fee schedule,,,616.2,,,fee schedule,,,,,,,,,1311.07,,,percent of total billed charges,,,,,,,,,,,,,,,104.89,,,percent of total billed charges,,,1311.07,,,percent of total billed charges,,,,,,,,,,,,,,,1311.07,,,percent of total billed charges,,,1311.07,,,percent of total billed charges,,,,,,,,,365.96,,,fee schedule,,,,,,,,,,,,,,,317.18,,,fee schedule,,,422.91,,,fee schedule,,,237.87,,,fee schedule,,,351.26,,,fee schedule,,,1311.07,,,percent of total billed charges,,,1311.07,,,percent of total billed charges,,,1311.07,,,percent of total billed charges,,,,,,,,,919.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,655.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,,,,,,service not payable
RABIES VACCINE 2.5 IU SYR IM,2500000341,CDM,636,RC,90675,CPT,5816096412,NDC,9139,APC,,outpatient,facility,1,UN,1311.07,1311.07,314.67,491.67,,,,,,,,337.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,327.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.06,,,fee schedule,,,,,,,,,479.85,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,327.78,,,fee schedule,,,,,,,,,,,,,,,344.17,,,fee schedule,,,344.17,,,fee schedule,,,,,,,,,327.78,,,fee schedule,,,327.78,,,fee schedule,,,344.17,,,fee schedule,,,,,,,,,,,,,,,491.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,327.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,314.67,,,fee schedule,,,350.72,,,fee schedule,,,344.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,327.78,,,fee schedule,,,327.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,340.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,327.78,,,fee schedule,,,,,,,,,409.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,409.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,327.78,,,fee schedule,,,327.78,,,fee schedule,,,,,,,,,,,,,,,327.78,,,fee schedule,,,,,,,,,327.78,,,fee schedule,,,337.61,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,327.78,,,fee schedule,,,,,,,,,,,,,,,340.89,,,fee schedule,,,327.78,,,fee schedule,,,,,,,,,327.78,,,fee schedule,,,,,,,,,327.78,,,fee schedule,,,344.17,,,fee schedule,,,,,,,,
RABIES VACCINE 2.5 IU SYR IM,2500000341,CDM,636,RC,90675,CPT,5816096412,NDC,415,EAPG,,outpatient,facility,1,UN,1311.07,1311.07,89.18,134.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.66,,,fee schedule,,,89.18,,,fee schedule,,,119.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.18,,,fee schedule,,,89.18,,,fee schedule,,,89.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,89.18,,,fee schedule,,,,,,,,,,,,,,,89.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TDAP VACCINE 7 YRS/> IM,2500000345,CDM,636,RC,90715,CPT,,,,,,inpatient,facility,0.5,UN,165.53,165.53,13.24,165.53,,,,,,,,,,,,,,165.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.53,,,percent of total billed charges,,,,,,,,,165.53,,,percent of total billed charges,,,84.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.32,,,percent of total billed charges,,,,,,,,,,,,,,,165.53,,,percent of total billed charges,,,140.7,,,percent of total billed charges,,,,,,,,,,,,,,,165.53,,,percent of total billed charges,,,87.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,165.53,,,percent of total billed charges,,,,,,,,,,,,,,,13.24,,,percent of total billed charges,,,165.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.53,,,percent of total billed charges,,
TDAP VACCINE 7 YRS/> IM,2500000345,CDM,636,RC,90715,CPT,,,,,,outpatient,facility,0.5,UN,165.53,165.53,13.24,548.68,,117.38,,,percent of total billed charges,,,40.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,165.53,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,165.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,60.58,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,38.54,,,fee schedule,,,165.53,,,fee schedule,,,165.53,,,percent of total billed charges,,,,,,,,,165.53,,,percent of total billed charges,,,101.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,97.66,,,percent of total billed charges,,,548.68,,,per diem,,,165.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,165.53,,,percent of total billed charges,,,140.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,87.91,,,percent of total billed charges,,,165.53,,,percent of total billed charges,,,165.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.67,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,,,,,,,,,,,,,66.21,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,165.53,,,percent of total billed charges,,,165.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,165.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.24,,,percent of total billed charges,,,165.53,,,percent of total billed charges,,,,,,,,,,,,,,,165.53,,,percent of total billed charges,,,165.53,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,39.73,,,fee schedule,,,165.53,,,percent of total billed charges,,,165.53,,,percent of total billed charges,,,165.53,,,percent of total billed charges,,,,,,,,,116.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,97.53,,,percent of total billed charges,,
TDAP VACCINE 7 YRS/> IM,2500000345,CDM,636,RC,90715,CPT,414,EAPG,,,,outpatient,facility,0.5,UN,165.53,165.53,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TETANUS DIPTHERIA TOX PF >7YRS,2500000381,CDM,636,RC,90714,CPT,4928121515,NDC,,,,inpatient,facility,0.5,UN,88.11,88.11,7.05,88.11,,,,,,,,,,,,,,88.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.11,,,percent of total billed charges,,,,,,,,,88.11,,,percent of total billed charges,,,44.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.87,,,percent of total billed charges,,,,,,,,,,,,,,,88.11,,,percent of total billed charges,,,74.89,,,percent of total billed charges,,,,,,,,,,,,,,,88.11,,,percent of total billed charges,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,88.11,,,percent of total billed charges,,,,,,,,,,,,,,,7.05,,,percent of total billed charges,,,88.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,88.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.91,,,percent of total billed charges,,
TETANUS DIPTHERIA TOX PF >7YRS,2500000381,CDM,636,RC,90714,CPT,4928121515,NDC,,,,outpatient,facility,0.5,UN,88.11,88.11,7.05,548.68,,62.48,,,percent of total billed charges,,,21.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,88.11,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,88.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,32.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,23.55,,,fee schedule,,,43.66,,,fee schedule,,,88.11,,,percent of total billed charges,,,,,,,,,88.11,,,percent of total billed charges,,,54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,51.98,,,percent of total billed charges,,,548.68,,,per diem,,,88.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,88.11,,,percent of total billed charges,,,74.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,88.11,,,percent of total billed charges,,,88.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.44,,,percent of total billed charges,,,71.3,,,percent of total billed charges,,,,,,,,,,,,,,,35.24,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,88.11,,,percent of total billed charges,,,88.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,88.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.05,,,percent of total billed charges,,,88.11,,,percent of total billed charges,,,,,,,,,,,,,,,88.11,,,percent of total billed charges,,,88.11,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,28.86,,,fee schedule,,,88.11,,,percent of total billed charges,,,88.11,,,percent of total billed charges,,,88.11,,,percent of total billed charges,,,,,,,,,61.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,51.91,,,percent of total billed charges,,
TETANUS DIPTHERIA TOX PF >7YRS,2500000381,CDM,636,RC,90714,CPT,4928121515,NDC,414,EAPG,,outpatient,facility,0.5,UN,88.11,88.11,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADENOSINE IV TX 6 MG,2500000410,CDM,636,RC,J0153,HCPCS,1747854202,NDC,,,,inpatient,facility,2,UN,24.55,24.55,1.96,24.55,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,24.55,,,percent of total billed charges,,,12.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.73,,,percent of total billed charges,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,20.87,,,percent of total billed charges,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.46,,,percent of total billed charges,,
ADENOSINE IV TX 6 MG,2500000410,CDM,636,RC,J0153,HCPCS,1747854202,NDC,,,,outpatient,facility,2,UN,24.55,24.55,0.44,548.68,,17.41,,,percent of total billed charges,,,5.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,24.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.99,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,24.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,24.55,,,fee schedule,,,24.55,,,percent of total billed charges,,,,,,,,,24.55,,,percent of total billed charges,,,15.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,14.48,,,percent of total billed charges,,,548.68,,,per diem,,,24.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,24.55,,,percent of total billed charges,,,20.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.56,,,percent of total billed charges,,,19.87,,,percent of total billed charges,,,,,,,,,,,,,,,9.82,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,24.55,,,percent of total billed charges,,,24.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.96,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.44,,,fee schedule,,,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,17.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.46,,,percent of total billed charges,,
ADENOSINE IV TX 6 MG,2500000410,CDM,636,RC,J0153,HCPCS,1747854202,NDC,435,EAPG,,outpatient,facility,2,UN,24.55,24.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADENOSINE IV DIAGNOSTIC 60 MG,2500000416,CDM,636,RC,J0153,HCPCS,5515019201,NDC,,,,inpatient,facility,20,ML,475.2,475.2,38.02,475.2,,,,,,,,,,,,,,475.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,475.2,,,percent of total billed charges,,,,,,,,,475.2,,,percent of total billed charges,,,242.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,285.12,,,percent of total billed charges,,,,,,,,,,,,,,,475.2,,,percent of total billed charges,,,403.92,,,percent of total billed charges,,,,,,,,,,,,,,,475.2,,,percent of total billed charges,,,252.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,475.2,,,percent of total billed charges,,,,,,,,,,,,,,,38.02,,,percent of total billed charges,,,475.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,475.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.99,,,percent of total billed charges,,
ADENOSINE IV DIAGNOSTIC 60 MG,2500000416,CDM,636,RC,J0153,HCPCS,5515019201,NDC,,,,outpatient,facility,20,ML,475.2,475.2,0.44,548.68,,336.96,,,percent of total billed charges,,,115.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,475.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,475.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,173.92,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,475.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,475.2,,,fee schedule,,,475.2,,,percent of total billed charges,,,,,,,,,475.2,,,percent of total billed charges,,,291.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,338.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,280.37,,,percent of total billed charges,,,548.68,,,per diem,,,475.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,475.2,,,percent of total billed charges,,,403.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,252.38,,,percent of total billed charges,,,475.2,,,percent of total billed charges,,,475.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,320.57,,,percent of total billed charges,,,384.53,,,percent of total billed charges,,,,,,,,,,,,,,,190.08,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,475.2,,,percent of total billed charges,,,475.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,475.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,38.02,,,percent of total billed charges,,,475.2,,,percent of total billed charges,,,,,,,,,,,,,,,475.2,,,percent of total billed charges,,,475.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.44,,,fee schedule,,,475.2,,,percent of total billed charges,,,475.2,,,percent of total billed charges,,,475.2,,,percent of total billed charges,,,,,,,,,333.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,279.99,,,percent of total billed charges,,
ADENOSINE IV DIAGNOSTIC 60 MG,2500000416,CDM,636,RC,J0153,HCPCS,5515019201,NDC,435,EAPG,,outpatient,facility,20,ML,475.2,475.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPINEPHRINE INJ 1 MG/10 ML,2500000422,CDM,636,RC,J0171,HCPCS,7632933161,NDC,,,,inpatient,facility,10,ML,28.87,28.87,2.31,28.87,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,,,,,,,28.87,,,percent of total billed charges,,,14.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.32,,,percent of total billed charges,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,24.54,,,percent of total billed charges,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,15.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.01,,,percent of total billed charges,,
EPINEPHRINE INJ 1 MG/10 ML,2500000422,CDM,636,RC,J0171,HCPCS,7632933161,NDC,,,,outpatient,facility,10,ML,28.87,28.87,0.49,548.68,,20.47,,,percent of total billed charges,,,7.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,28.87,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.49,,,fee schedule,,,28.87,,,fee schedule,,,28.87,,,percent of total billed charges,,,,,,,,,28.87,,,percent of total billed charges,,,17.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,17.03,,,percent of total billed charges,,,548.68,,,per diem,,,28.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,28.87,,,percent of total billed charges,,,24.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.33,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.48,,,percent of total billed charges,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,28.87,,,percent of total billed charges,,,28.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.31,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.84,,,fee schedule,,,28.87,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,,,,,,,20.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.01,,,percent of total billed charges,,
EPINEPHRINE INJ 1 MG/10 ML,2500000422,CDM,636,RC,J0171,HCPCS,7632933161,NDC,496,EAPG,,outpatient,facility,10,ML,28.87,28.87,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPINEPHRINE INJ 30 MG/30 ML,2500000424,CDM,636,RC,J0171,HCPCS,7632990600,NDC,,,,inpatient,facility,30,ML,641.45,641.45,51.32,641.45,,,,,,,,,,,,,,641.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.45,,,percent of total billed charges,,,,,,,,,641.45,,,percent of total billed charges,,,327.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,546.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.87,,,percent of total billed charges,,,,,,,,,,,,,,,641.45,,,percent of total billed charges,,,545.23,,,percent of total billed charges,,,,,,,,,,,,,,,641.45,,,percent of total billed charges,,,340.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,641.45,,,percent of total billed charges,,,,,,,,,,,,,,,51.32,,,percent of total billed charges,,,641.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,641.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.94,,,percent of total billed charges,,
EPINEPHRINE INJ 30 MG/30 ML,2500000424,CDM,636,RC,J0171,HCPCS,7632990600,NDC,,,,outpatient,facility,30,ML,641.45,641.45,0.49,641.45,,454.85,,,percent of total billed charges,,,156.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,641.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,641.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,234.77,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.49,,,fee schedule,,,641.45,,,fee schedule,,,641.45,,,percent of total billed charges,,,,,,,,,641.45,,,percent of total billed charges,,,393.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,457.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,378.46,,,percent of total billed charges,,,548.68,,,per diem,,,641.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,641.45,,,percent of total billed charges,,,545.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,340.67,,,percent of total billed charges,,,641.45,,,percent of total billed charges,,,641.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,432.72,,,percent of total billed charges,,,519.06,,,percent of total billed charges,,,,,,,,,,,,,,,256.58,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,641.45,,,percent of total billed charges,,,641.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,641.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,51.32,,,percent of total billed charges,,,641.45,,,percent of total billed charges,,,,,,,,,,,,,,,641.45,,,percent of total billed charges,,,641.45,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.84,,,fee schedule,,,641.45,,,percent of total billed charges,,,641.45,,,percent of total billed charges,,,641.45,,,percent of total billed charges,,,,,,,,,449.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,320.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,377.94,,,percent of total billed charges,,
EPINEPHRINE INJ 30 MG/30 ML,2500000424,CDM,636,RC,J0171,HCPCS,7632990600,NDC,496,EAPG,,outpatient,facility,30,ML,641.45,641.45,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMPICILLIN INJ 500MG,2500000500,CDM,636,RC,J0290,HCPCS,409371801,NDC,,,,inpatient,facility,5,UN,7.72,7.72,0.62,7.72,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,,,,,,,7.72,,,percent of total billed charges,,,3.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,4.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,
AMPICILLIN INJ 500MG,2500000500,CDM,636,RC,J0290,HCPCS,409371801,NDC,,,,outpatient,facility,5,UN,7.72,7.72,0.62,548.68,,5.47,,,percent of total billed charges,,,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.72,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.83,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.93,,,fee schedule,,,7.72,,,fee schedule,,,7.72,,,percent of total billed charges,,,,,,,,,7.72,,,percent of total billed charges,,,4.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,4.55,,,percent of total billed charges,,,548.68,,,per diem,,,7.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.72,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.1,,,percent of total billed charges,,,7.72,,,percent of total billed charges,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,6.25,,,percent of total billed charges,,,,,,,,,,,,,,,3.09,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7.72,,,percent of total billed charges,,,7.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.62,,,percent of total billed charges,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.91,,,fee schedule,,,7.72,,,percent of total billed charges,,,7.72,,,percent of total billed charges,,,7.72,,,percent of total billed charges,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.86,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.55,,,percent of total billed charges,,
AMPICILLIN INJ 500MG,2500000500,CDM,636,RC,J0290,HCPCS,409371801,NDC,496,EAPG,,outpatient,facility,5,UN,7.72,7.72,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMPICILLIN INJ 1 GM,2500000502,CDM,636,RC,J0290,HCPCS,5515011310,NDC,,,,inpatient,facility,1,UN,27.09,27.09,2.17,27.09,,,,,,,,,,,,,,27.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.09,,,percent of total billed charges,,,,,,,,,27.09,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.25,,,percent of total billed charges,,,,,,,,,,,,,,,27.09,,,percent of total billed charges,,,23.03,,,percent of total billed charges,,,,,,,,,,,,,,,27.09,,,percent of total billed charges,,,14.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,27.09,,,percent of total billed charges,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,27.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.96,,,percent of total billed charges,,
AMPICILLIN INJ 1 GM,2500000502,CDM,636,RC,J0290,HCPCS,5515011310,NDC,,,,outpatient,facility,1,UN,27.09,27.09,0.91,548.68,,19.21,,,percent of total billed charges,,,6.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,27.09,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,27.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.93,,,fee schedule,,,27.09,,,fee schedule,,,27.09,,,percent of total billed charges,,,,,,,,,27.09,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,15.98,,,percent of total billed charges,,,548.68,,,per diem,,,27.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,27.09,,,percent of total billed charges,,,23.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.39,,,percent of total billed charges,,,27.09,,,percent of total billed charges,,,27.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.27,,,percent of total billed charges,,,21.92,,,percent of total billed charges,,,,,,,,,,,,,,,10.84,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,27.09,,,percent of total billed charges,,,27.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.17,,,percent of total billed charges,,,27.09,,,percent of total billed charges,,,,,,,,,,,,,,,27.09,,,percent of total billed charges,,,27.09,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.91,,,fee schedule,,,27.09,,,percent of total billed charges,,,27.09,,,percent of total billed charges,,,27.09,,,percent of total billed charges,,,,,,,,,18.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15.96,,,percent of total billed charges,,
AMPICILLIN INJ 1 GM,2500000502,CDM,636,RC,J0290,HCPCS,5515011310,NDC,496,EAPG,,outpatient,facility,1,UN,27.09,27.09,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMPICILLIN INJ 2 GM,2500000504,CDM,636,RC,J0290,HCPCS,6745735210,NDC,,,,inpatient,facility,2,UN,52.54,52.54,4.2,52.54,,,,,,,,,,,,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.54,,,percent of total billed charges,,,,,,,,,52.54,,,percent of total billed charges,,,26.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,52.54,,,percent of total billed charges,,,44.66,,,percent of total billed charges,,,,,,,,,,,,,,,52.54,,,percent of total billed charges,,,27.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,,4.2,,,percent of total billed charges,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.96,,,percent of total billed charges,,
AMPICILLIN INJ 2 GM,2500000504,CDM,636,RC,J0290,HCPCS,6745735210,NDC,,,,outpatient,facility,2,UN,52.54,52.54,0.91,548.68,,37.26,,,percent of total billed charges,,,12.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,52.54,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,19.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.93,,,fee schedule,,,52.54,,,fee schedule,,,52.54,,,percent of total billed charges,,,,,,,,,52.54,,,percent of total billed charges,,,32.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,31,,,percent of total billed charges,,,548.68,,,per diem,,,52.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,52.54,,,percent of total billed charges,,,44.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.9,,,percent of total billed charges,,,52.54,,,percent of total billed charges,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,42.52,,,percent of total billed charges,,,,,,,,,,,,,,,21.02,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,52.54,,,percent of total billed charges,,,52.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,52.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.2,,,percent of total billed charges,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,,52.54,,,percent of total billed charges,,,52.54,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.91,,,fee schedule,,,52.54,,,percent of total billed charges,,,52.54,,,percent of total billed charges,,,52.54,,,percent of total billed charges,,,,,,,,,36.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,30.96,,,percent of total billed charges,,
AMPICILLIN INJ 2 GM,2500000504,CDM,636,RC,J0290,HCPCS,6745735210,NDC,496,EAPG,,outpatient,facility,2,UN,52.54,52.54,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMPICILLIN/SULBACTAM 1.5 GM,2500000510,CDM,636,RC,J0295,HCPCS,4456721010,NDC,,,,inpatient,facility,1.5,UN,31.48,31.48,2.52,31.48,,,,,,,,,,,,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.48,,,percent of total billed charges,,,,,,,,,31.48,,,percent of total billed charges,,,16.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.89,,,percent of total billed charges,,,,,,,,,,,,,,,31.48,,,percent of total billed charges,,,26.76,,,percent of total billed charges,,,,,,,,,,,,,,,31.48,,,percent of total billed charges,,,16.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.55,,,percent of total billed charges,,
AMPICILLIN/SULBACTAM 1.5 GM,2500000510,CDM,636,RC,J0295,HCPCS,4456721010,NDC,,,,outpatient,facility,1.5,UN,31.48,31.48,2.01,548.68,,22.32,,,percent of total billed charges,,,7.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,31.48,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.52,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.83,,,fee schedule,,,31.48,,,fee schedule,,,31.48,,,percent of total billed charges,,,,,,,,,31.48,,,percent of total billed charges,,,19.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,18.57,,,percent of total billed charges,,,548.68,,,per diem,,,31.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,31.48,,,percent of total billed charges,,,26.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.72,,,percent of total billed charges,,,31.48,,,percent of total billed charges,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.24,,,percent of total billed charges,,,25.47,,,percent of total billed charges,,,,,,,,,,,,,,,12.59,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,31.48,,,percent of total billed charges,,,31.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.52,,,percent of total billed charges,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,,31.48,,,percent of total billed charges,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.01,,,fee schedule,,,31.48,,,percent of total billed charges,,,31.48,,,percent of total billed charges,,,31.48,,,percent of total billed charges,,,,,,,,,22.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.55,,,percent of total billed charges,,
AMPICILLIN/SULBACTAM 1.5 GM,2500000510,CDM,636,RC,J0295,HCPCS,4456721010,NDC,496,EAPG,,outpatient,facility,1.5,UN,31.48,31.48,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMPICILLIN/SULBACTAM  3 GM,2500000512,CDM,636,RC,J0295,HCPCS,5515011720,NDC,,,,inpatient,facility,3,UN,48.18,48.18,3.85,48.18,,,,,,,,,,,,,,48.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.18,,,percent of total billed charges,,,,,,,,,48.18,,,percent of total billed charges,,,24.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.91,,,percent of total billed charges,,,,,,,,,,,,,,,48.18,,,percent of total billed charges,,,40.95,,,percent of total billed charges,,,,,,,,,,,,,,,48.18,,,percent of total billed charges,,,25.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,48.18,,,percent of total billed charges,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,48.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.39,,,percent of total billed charges,,
AMPICILLIN/SULBACTAM  3 GM,2500000512,CDM,636,RC,J0295,HCPCS,5515011720,NDC,,,,outpatient,facility,3,UN,48.18,48.18,2.01,548.68,,34.16,,,percent of total billed charges,,,11.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,48.18,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,48.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,17.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.83,,,fee schedule,,,48.18,,,fee schedule,,,48.18,,,percent of total billed charges,,,,,,,,,48.18,,,percent of total billed charges,,,29.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,28.43,,,percent of total billed charges,,,548.68,,,per diem,,,48.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,48.18,,,percent of total billed charges,,,40.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.59,,,percent of total billed charges,,,48.18,,,percent of total billed charges,,,48.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.5,,,percent of total billed charges,,,38.99,,,percent of total billed charges,,,,,,,,,,,,,,,19.27,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,48.18,,,percent of total billed charges,,,48.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,48.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.85,,,percent of total billed charges,,,48.18,,,percent of total billed charges,,,,,,,,,,,,,,,48.18,,,percent of total billed charges,,,48.18,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.01,,,fee schedule,,,48.18,,,percent of total billed charges,,,48.18,,,percent of total billed charges,,,48.18,,,percent of total billed charges,,,,,,,,,33.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,28.39,,,percent of total billed charges,,
AMPICILLIN/SULBACTAM  3 GM,2500000512,CDM,636,RC,J0295,HCPCS,5515011720,NDC,496,EAPG,,outpatient,facility,3,UN,48.18,48.18,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUCCINYLCHOLINE INJ 200 MG,2500000532,CDM,636,RC,J0330,HCPCS,409662902,NDC,,,,inpatient,facility,10,ML,63.92,63.92,5.11,63.92,,,,,,,,,,,,,,63.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.92,,,percent of total billed charges,,,,,,,,,63.92,,,percent of total billed charges,,,32.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.35,,,percent of total billed charges,,,,,,,,,,,,,,,63.92,,,percent of total billed charges,,,54.33,,,percent of total billed charges,,,,,,,,,,,,,,,63.92,,,percent of total billed charges,,,33.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,63.92,,,percent of total billed charges,,,,,,,,,,,,,,,5.11,,,percent of total billed charges,,,63.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.66,,,percent of total billed charges,,
SUCCINYLCHOLINE INJ 200 MG,2500000532,CDM,636,RC,J0330,HCPCS,409662902,NDC,,,,outpatient,facility,10,ML,63.92,63.92,0.85,548.68,,45.33,,,percent of total billed charges,,,15.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,63.92,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,63.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,23.39,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,63.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,63.92,,,fee schedule,,,63.92,,,percent of total billed charges,,,,,,,,,63.92,,,percent of total billed charges,,,39.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,37.71,,,percent of total billed charges,,,548.68,,,per diem,,,63.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,63.92,,,percent of total billed charges,,,54.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.95,,,percent of total billed charges,,,63.92,,,percent of total billed charges,,,63.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.12,,,percent of total billed charges,,,51.72,,,percent of total billed charges,,,,,,,,,,,,,,,25.57,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,63.92,,,percent of total billed charges,,,63.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,63.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.11,,,percent of total billed charges,,,63.92,,,percent of total billed charges,,,,,,,,,,,,,,,63.92,,,percent of total billed charges,,,63.92,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,63.92,,,percent of total billed charges,,,63.92,,,percent of total billed charges,,,63.92,,,percent of total billed charges,,,,,,,,,44.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,37.66,,,percent of total billed charges,,
SUCCINYLCHOLINE INJ 200 MG,2500000532,CDM,636,RC,J0330,HCPCS,409662902,NDC,999,EAPG,,outpatient,facility,10,ML,63.92,63.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDRALAZINE HCL INJ 20 MG,2500000560,CDM,636,RC,J0360,HCPCS,6332361401,NDC,,,,inpatient,facility,1,ML,47.26,47.26,3.78,47.26,,,,,,,,,,,,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.26,,,percent of total billed charges,,,,,,,,,47.26,,,percent of total billed charges,,,24.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.36,,,percent of total billed charges,,,,,,,,,,,,,,,47.26,,,percent of total billed charges,,,40.17,,,percent of total billed charges,,,,,,,,,,,,,,,47.26,,,percent of total billed charges,,,25.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,,3.78,,,percent of total billed charges,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.85,,,percent of total billed charges,,
HYDRALAZINE HCL INJ 20 MG,2500000560,CDM,636,RC,J0360,HCPCS,6332361401,NDC,,,,outpatient,facility,1,ML,47.26,47.26,3.78,548.68,,33.51,,,percent of total billed charges,,,11.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,47.26,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,17.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,47.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,47.26,,,fee schedule,,,47.26,,,percent of total billed charges,,,,,,,,,47.26,,,percent of total billed charges,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,27.88,,,percent of total billed charges,,,548.68,,,per diem,,,47.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,47.26,,,percent of total billed charges,,,40.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.1,,,percent of total billed charges,,,47.26,,,percent of total billed charges,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.88,,,percent of total billed charges,,,38.24,,,percent of total billed charges,,,,,,,,,,,,,,,18.9,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,47.26,,,percent of total billed charges,,,47.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,47.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.78,,,percent of total billed charges,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,,47.26,,,percent of total billed charges,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,4.27,,,fee schedule,,,47.26,,,percent of total billed charges,,,47.26,,,percent of total billed charges,,,47.26,,,percent of total billed charges,,,,,,,,,33.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,27.85,,,percent of total billed charges,,
HYDRALAZINE HCL INJ 20 MG,2500000560,CDM,636,RC,J0360,HCPCS,6332361401,NDC,999,EAPG,,outpatient,facility,1,ML,47.26,47.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATROPINE SULF INJ 1 MG/10 ML,2500000607,CDM,636,RC,J0461,HCPCS,7632933401,NDC,,,,inpatient,facility,10,UN,37.78,37.78,3.02,37.78,,,,,,,,,,,,,,37.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.78,,,percent of total billed charges,,,,,,,,,37.78,,,percent of total billed charges,,,19.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.67,,,percent of total billed charges,,,,,,,,,,,,,,,37.78,,,percent of total billed charges,,,32.11,,,percent of total billed charges,,,,,,,,,,,,,,,37.78,,,percent of total billed charges,,,20.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,37.78,,,percent of total billed charges,,,,,,,,,,,,,,,3.02,,,percent of total billed charges,,,37.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.26,,,percent of total billed charges,,
ATROPINE SULF INJ 1 MG/10 ML,2500000607,CDM,636,RC,J0461,HCPCS,7632933401,NDC,,,,outpatient,facility,10,UN,37.78,37.78,0.02,548.68,,26.79,,,percent of total billed charges,,,9.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,37.78,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,37.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,13.83,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.02,,,fee schedule,,,37.78,,,fee schedule,,,37.78,,,percent of total billed charges,,,,,,,,,37.78,,,percent of total billed charges,,,23.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,22.29,,,percent of total billed charges,,,548.68,,,per diem,,,37.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,37.78,,,percent of total billed charges,,,32.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.06,,,percent of total billed charges,,,37.78,,,percent of total billed charges,,,37.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.49,,,percent of total billed charges,,,30.57,,,percent of total billed charges,,,,,,,,,,,,,,,15.11,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,37.78,,,percent of total billed charges,,,37.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,37.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.02,,,percent of total billed charges,,,37.78,,,percent of total billed charges,,,,,,,,,,,,,,,37.78,,,percent of total billed charges,,,37.78,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.09,,,fee schedule,,,37.78,,,percent of total billed charges,,,37.78,,,percent of total billed charges,,,37.78,,,percent of total billed charges,,,,,,,,,26.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,22.26,,,percent of total billed charges,,
ATROPINE SULF INJ 1 MG/10 ML,2500000607,CDM,636,RC,J0461,HCPCS,7632933401,NDC,496,EAPG,,outpatient,facility,10,UN,37.78,37.78,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DICYCLOMINE HCL INJ 20 MG,2500000630,CDM,636,RC,J0500,HCPCS,7226612705,NDC,,,,inpatient,facility,2,ML,81.18,81.18,6.49,81.18,,,,,,,,,,,,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.18,,,percent of total billed charges,,,,,,,,,81.18,,,percent of total billed charges,,,41.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.71,,,percent of total billed charges,,,,,,,,,,,,,,,81.18,,,percent of total billed charges,,,69,,,percent of total billed charges,,,,,,,,,,,,,,,81.18,,,percent of total billed charges,,,43.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,6.49,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.83,,,percent of total billed charges,,
DICYCLOMINE HCL INJ 20 MG,2500000630,CDM,636,RC,J0500,HCPCS,7226612705,NDC,,,,outpatient,facility,2,ML,81.18,81.18,6.49,548.68,,57.56,,,percent of total billed charges,,,19.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,81.18,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,29.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,81.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,81.18,,,fee schedule,,,81.18,,,percent of total billed charges,,,,,,,,,81.18,,,percent of total billed charges,,,49.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,47.9,,,percent of total billed charges,,,548.68,,,per diem,,,81.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,81.18,,,percent of total billed charges,,,69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.11,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.76,,,percent of total billed charges,,,65.69,,,percent of total billed charges,,,,,,,,,,,,,,,32.47,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,81.18,,,percent of total billed charges,,,81.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,81.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.49,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,81.18,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,21.1,,,fee schedule,,,81.18,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,,,,,,,56.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,47.83,,,percent of total billed charges,,
DICYCLOMINE HCL INJ 20 MG,2500000630,CDM,636,RC,J0500,HCPCS,7226612705,NDC,999,EAPG,,outpatient,facility,2,ML,81.18,81.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENZTROPINE MESY INJ 2 MG,2500000642,CDM,636,RC,J0515,HCPCS,143972905,NDC,,,,inpatient,facility,2,UN,198,198,15.84,198,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,198,,,percent of total billed charges,,,101.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,168.3,,,percent of total billed charges,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,105.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,15.84,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.66,,,percent of total billed charges,,
BENZTROPINE MESY INJ 2 MG,2500000642,CDM,636,RC,J0515,HCPCS,143972905,NDC,,,,outpatient,facility,2,UN,198,198,15.84,548.68,,140.4,,,percent of total billed charges,,,48.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,198,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,72.47,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,198,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,198,,,fee schedule,,,198,,,percent of total billed charges,,,,,,,,,198,,,percent of total billed charges,,,121.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,116.82,,,percent of total billed charges,,,548.68,,,per diem,,,198,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,198,,,percent of total billed charges,,,168.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,105.16,,,percent of total billed charges,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.57,,,percent of total billed charges,,,160.22,,,percent of total billed charges,,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,198,,,percent of total billed charges,,,198,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,198,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.84,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,16.91,,,fee schedule,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,138.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,116.66,,,percent of total billed charges,,
BENZTROPINE MESY INJ 2 MG,2500000642,CDM,636,RC,J0515,HCPCS,143972905,NDC,999,EAPG,,outpatient,facility,2,UN,198,198,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PENICILLIN G BENZ 1200000 U,2500000710,CDM,636,RC,J0561,HCPCS,6079370110,NDC,,,,inpatient,facility,2,ML,914.96,914.96,73.2,914.96,,,,,,,,,,,,,,914.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,914.96,,,percent of total billed charges,,,,,,,,,914.96,,,percent of total billed charges,,,467.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,779.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,548.98,,,percent of total billed charges,,,,,,,,,,,,,,,914.96,,,percent of total billed charges,,,777.72,,,percent of total billed charges,,,,,,,,,,,,,,,914.96,,,percent of total billed charges,,,485.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,365.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,914.96,,,percent of total billed charges,,,,,,,,,,,,,,,73.2,,,percent of total billed charges,,,914.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,914.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,539.09,,,percent of total billed charges,,
PENICILLIN G BENZ 1200000 U,2500000710,CDM,636,RC,J0561,HCPCS,6079370110,NDC,,,,outpatient,facility,2,ML,914.96,914.96,4.94,914.96,,648.8,,,percent of total billed charges,,,,,,,,,914.96,,,percent of total billed charges,,,31.11,,,fee schedule,,,29.44,,,fee schedule,,,,,,,,,29.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,914.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.94,,,fee schedule,,,914.96,,,fee schedule,,,914.96,,,percent of total billed charges,,,,,,,,,914.96,,,percent of total billed charges,,,560.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.91,,,percent of total billed charges,,,,,,,,,,,,,,,21.73,,,fee schedule,,,21.73,,,fee schedule,,,21.73,,,fee schedule,,,,,,,,,539.83,,,percent of total billed charges,,,548.68,,,per diem,,,914.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,914.96,,,percent of total billed charges,,,777.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,485.94,,,percent of total billed charges,,,914.96,,,percent of total billed charges,,,914.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,617.23,,,percent of total billed charges,,,740.39,,,percent of total billed charges,,,,,,,,,,,,,,,365.98,,,percent of total billed charges,,,,,,,,,41.11,,,fee schedule,,,29.58,,,fee schedule,,,,,,,,,914.96,,,percent of total billed charges,,,,,,,,,,,,,,,73.2,,,percent of total billed charges,,,914.96,,,percent of total billed charges,,,,,,,,,,,,,,,914.96,,,percent of total billed charges,,,914.96,,,percent of total billed charges,,,,,,,,,17.57,,,fee schedule,,,,,,,,,,,,,,,15.23,,,fee schedule,,,20.3,,,fee schedule,,,11.42,,,fee schedule,,,24.88,,,fee schedule,,,914.96,,,percent of total billed charges,,,914.96,,,percent of total billed charges,,,914.96,,,percent of total billed charges,,,,,,,,,641.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,457.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,539.09,,,percent of total billed charges,,
PENICILLIN G BENZ 1200000 U,2500000710,CDM,636,RC,J0561,HCPCS,6079370110,NDC,1829,APC,,outpatient,facility,2,ML,914.96,914.96,25.75,334.88,,,,,,,,27.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,26.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.09,,,fee schedule,,,,,,,,,334.88,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,26.82,,,fee schedule,,,,,,,,,,,,,,,28.16,,,fee schedule,,,28.16,,,fee schedule,,,,,,,,,26.82,,,fee schedule,,,26.82,,,fee schedule,,,28.16,,,fee schedule,,,,,,,,,,,,,,,40.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,26.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.75,,,fee schedule,,,28.7,,,fee schedule,,,28.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.82,,,fee schedule,,,26.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,27.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,26.82,,,fee schedule,,,,,,,,,33.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,26.82,,,fee schedule,,,26.82,,,fee schedule,,,,,,,,,,,,,,,26.82,,,fee schedule,,,,,,,,,26.82,,,fee schedule,,,27.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.82,,,fee schedule,,,,,,,,,,,,,,,27.89,,,fee schedule,,,26.82,,,fee schedule,,,,,,,,,26.82,,,fee schedule,,,,,,,,,26.82,,,fee schedule,,,28.16,,,fee schedule,,,,,,,,
PENICILLIN G BENZ 1200000 U,2500000710,CDM,636,RC,J0561,HCPCS,6079370110,NDC,436,EAPG,,outpatient,facility,2,ML,914.96,914.96,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCIUM GLUCONATE 100 ML INJ,2500000764,CDM,250,RC,J0613,HCPCS,,,,,,inpatient,facility,1,UN,156.42,156.42,12.51,156.42,,,,,,,,,,,,,,156.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.42,,,percent of total billed charges,,,,,,,,,156.42,,,percent of total billed charges,,,79.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.85,,,percent of total billed charges,,,,,,,,,,,,,,,156.42,,,percent of total billed charges,,,132.96,,,percent of total billed charges,,,,,,,,,,,,,,,156.42,,,percent of total billed charges,,,83.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,156.42,,,percent of total billed charges,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,156.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,156.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.16,,,percent of total billed charges,,
CALCIUM GLUCONATE 100 ML INJ,2500000764,CDM,250,RC,J0613,HCPCS,,,,,,outpatient,facility,1,UN,156.42,156.42,0.09,548.68,,110.92,,,percent of total billed charges,,,38.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,156.42,,,percent of total billed charges,,,0.12,,,fee schedule,,,0.11,,,fee schedule,,,,,,,,,0.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,156.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,57.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,156.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,156.42,,,fee schedule,,,156.42,,,percent of total billed charges,,,,,,,,,156.42,,,percent of total billed charges,,,95.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,92.29,,,percent of total billed charges,,,548.68,,,per diem,,,156.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,156.42,,,percent of total billed charges,,,132.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,83.07,,,percent of total billed charges,,,156.42,,,percent of total billed charges,,,156.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.52,,,percent of total billed charges,,,126.58,,,percent of total billed charges,,,,,,,,,,,,,,,62.57,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,156.42,,,percent of total billed charges,,,156.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,156.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.51,,,percent of total billed charges,,,156.42,,,percent of total billed charges,,,,,,,,,,,,,,,156.42,,,percent of total billed charges,,,156.42,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.09,,,fee schedule,,,156.42,,,percent of total billed charges,,,156.42,,,percent of total billed charges,,,156.42,,,percent of total billed charges,,,,,,,,,109.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,92.16,,,percent of total billed charges,,
CALCIUM GLUCONATE 100 ML INJ,2500000764,CDM,250,RC,J0613,HCPCS,999,EAPG,,,,outpatient,facility,1,UN,156.42,156.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCITONIN SALMON INJ 400 U,2500000780,CDM,636,RC,J0630,HCPCS,6745767502,NDC,,,,inpatient,facility,2,ML,10704.14,10704.14,856.33,10704.14,,,,,,,,,,,,,,10704.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10704.14,,,percent of total billed charges,,,,,,,,,10704.14,,,percent of total billed charges,,,5465.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9116.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6422.48,,,percent of total billed charges,,,,,,,,,,,,,,,10704.14,,,percent of total billed charges,,,9098.52,,,percent of total billed charges,,,,,,,,,,,,,,,10704.14,,,percent of total billed charges,,,5684.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4281.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10704.14,,,percent of total billed charges,,,,,,,,,,,,,,,856.33,,,percent of total billed charges,,,10704.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10704.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6306.88,,,percent of total billed charges,,
CALCITONIN SALMON INJ 400 U,2500000780,CDM,636,RC,J0630,HCPCS,6745767502,NDC,,,,outpatient,facility,2,ML,10704.14,10704.14,357.82,10704.14,,7590.31,,,percent of total billed charges,,,,,,,,,10704.14,,,percent of total billed charges,,,1391.42,,,fee schedule,,,1316.38,,,fee schedule,,,,,,,,,1316.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,10704.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10704.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10704.14,,,fee schedule,,,10704.14,,,percent of total billed charges,,,,,,,,,10704.14,,,percent of total billed charges,,,6560.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7626.7,,,percent of total billed charges,,,,,,,,,,,,,,,1069.5,,,fee schedule,,,1069.5,,,fee schedule,,,1069.5,,,fee schedule,,,,,,,,,6315.44,,,percent of total billed charges,,,548.68,,,per diem,,,10704.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10704.14,,,percent of total billed charges,,,9098.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5684.97,,,percent of total billed charges,,,10704.14,,,percent of total billed charges,,,10704.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7221.01,,,percent of total billed charges,,,8661.79,,,percent of total billed charges,,,,,,,,,,,,,,,4281.66,,,percent of total billed charges,,,,,,,,,4366.92,,,fee schedule,,,3142.34,,,fee schedule,,,,,,,,,10704.14,,,percent of total billed charges,,,,,,,,,,,,,,,856.33,,,percent of total billed charges,,,10704.14,,,percent of total billed charges,,,,,,,,,,,,,,,10704.14,,,percent of total billed charges,,,10704.14,,,percent of total billed charges,,,,,,,,,1866.21,,,fee schedule,,,,,,,,,,,,,,,1617.47,,,fee schedule,,,2156.62,,,fee schedule,,,1213.04,,,fee schedule,,,1112.42,,,fee schedule,,,10704.14,,,percent of total billed charges,,,10704.14,,,percent of total billed charges,,,10704.14,,,percent of total billed charges,,,,,,,,,7504.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5352.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6306.88,,,percent of total billed charges,,
CALCITONIN SALMON INJ 400 U,2500000780,CDM,636,RC,J0630,HCPCS,6745767502,NDC,1433,APC,,outpatient,facility,2,ML,10704.14,10704.14,1096.71,3917.72,,,,,,,,1176.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1142.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1153.83,,,fee schedule,,,,,,,,,3917.72,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,1142.41,,,fee schedule,,,,,,,,,,,,,,,1199.53,,,fee schedule,,,1199.53,,,fee schedule,,,,,,,,,1142.41,,,fee schedule,,,1142.41,,,fee schedule,,,1199.53,,,fee schedule,,,,,,,,,,,,,,,1713.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1142.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1096.71,,,fee schedule,,,1222.38,,,fee schedule,,,1199.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1142.41,,,fee schedule,,,1142.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1188.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1142.41,,,fee schedule,,,,,,,,,1428.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1428.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,1142.41,,,fee schedule,,,1142.41,,,fee schedule,,,,,,,,,,,,,,,1142.41,,,fee schedule,,,,,,,,,1142.41,,,fee schedule,,,1176.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1142.41,,,fee schedule,,,,,,,,,,,,,,,1188.11,,,fee schedule,,,1142.41,,,fee schedule,,,,,,,,,1142.41,,,fee schedule,,,,,,,,,1142.41,,,fee schedule,,,1199.53,,,fee schedule,,,,,,,,
CALCITONIN SALMON INJ 400 U,2500000780,CDM,636,RC,J0630,HCPCS,6745767502,NDC,999,EAPG,,outpatient,facility,2,ML,10704.14,10704.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCITONIN NASL 200IU ACT3.7ML,2500000785,CDM,637,RC,4988416111,NDC,,,,,,inpatient,facility,3.7,UN,391.18,391.18,31.29,391.18,,,,,,,,,,,,,,391.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.18,,,percent of total billed charges,,,,,,,,,391.18,,,percent of total billed charges,,,199.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,333.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.71,,,percent of total billed charges,,,,,,,,,,,,,,,391.18,,,percent of total billed charges,,,332.5,,,percent of total billed charges,,,,,,,,,,,,,,,391.18,,,percent of total billed charges,,,207.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,391.18,,,percent of total billed charges,,,,,,,,,,,,,,,31.29,,,percent of total billed charges,,,391.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,391.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.48,,,percent of total billed charges,,
CALCITONIN NASL 200IU ACT3.7ML,2500000785,CDM,637,RC,4988416111,NDC,,,,,,outpatient,facility,3.7,UN,391.18,391.18,31.29,548.68,,277.39,,,percent of total billed charges,,,95.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,391.18,,,percent of total billed charges,,,245.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,275,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,275,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,391.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,143.17,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,391.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,391.18,,,fee schedule,,,391.18,,,percent of total billed charges,,,,,,,,,391.18,,,percent of total billed charges,,,239.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.72,,,percent of total billed charges,,,,,,,,,,,,,,,211.24,,,percent of total billed charges,,,203.41,,,percent of total billed charges,,,215.15,,,percent of total billed charges,,,,,,,,,230.8,,,percent of total billed charges,,,548.68,,,per diem,,,391.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,391.18,,,percent of total billed charges,,,332.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,207.76,,,percent of total billed charges,,,391.18,,,percent of total billed charges,,,391.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.89,,,percent of total billed charges,,,316.54,,,percent of total billed charges,,,,,,,,,,,,,,,156.47,,,percent of total billed charges,,,,,,,,,144.74,,,percent of total billed charges,,,144.74,,,percent of total billed charges,,,,,,,,,391.18,,,percent of total billed charges,,,391.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,391.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.29,,,percent of total billed charges,,,391.18,,,percent of total billed charges,,,,,,,,,,,,,,,391.18,,,percent of total billed charges,,,391.18,,,percent of total billed charges,,,,,,,,,363.88,,,percent of total billed charges,,,,,,,,,,,,,,,363.88,,,percent of total billed charges,,,363.88,,,percent of total billed charges,,,363.88,,,percent of total billed charges,,,293.38,,,percent of total billed charges,,,391.18,,,percent of total billed charges,,,391.18,,,percent of total billed charges,,,391.18,,,percent of total billed charges,,,,,,,,,274.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,230.48,,,percent of total billed charges,,
CALCITONIN NASL 200IU ACT3.7ML,2500000785,CDM,637,RC,4988416111,NDC,999,EAPG,,,,outpatient,facility,3.7,UN,391.18,391.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEUCOVORIN CALCIUM INJ 50 MG,2500000800,CDM,636,RC,J0640,HCPCS,143955501,NDC,,,,inpatient,facility,50,GR,33,33,2.64,33,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,16.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,17.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.44,,,percent of total billed charges,,
LEUCOVORIN CALCIUM INJ 50 MG,2500000800,CDM,636,RC,J0640,HCPCS,143955501,NDC,,,,outpatient,facility,50,GR,33,33,1.44,548.68,,23.4,,,percent of total billed charges,,,8.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,33,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.44,,,fee schedule,,,33,,,fee schedule,,,33,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,20.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,19.47,,,percent of total billed charges,,,548.68,,,per diem,,,33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,33,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.53,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.26,,,percent of total billed charges,,,26.7,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,33,,,percent of total billed charges,,,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.64,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,4.6,,,fee schedule,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,23.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,19.44,,,percent of total billed charges,,
LEUCOVORIN CALCIUM INJ 50 MG,2500000800,CDM,636,RC,J0640,HCPCS,143955501,NDC,430,EAPG,,outpatient,facility,50,GR,33,33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEUCOVORIN CALCIUM INJ 100 MG,2500000802,CDM,636,RC,J0640,HCPCS,143955401,NDC,,,,inpatient,facility,100,GR,52.8,52.8,4.22,52.8,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,52.8,,,percent of total billed charges,,,26.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,44.88,,,percent of total billed charges,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,28.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.11,,,percent of total billed charges,,
LEUCOVORIN CALCIUM INJ 100 MG,2500000802,CDM,636,RC,J0640,HCPCS,143955401,NDC,,,,outpatient,facility,100,GR,52.8,52.8,1.44,548.68,,37.44,,,percent of total billed charges,,,12.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,52.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,19.32,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.44,,,fee schedule,,,52.8,,,fee schedule,,,52.8,,,percent of total billed charges,,,,,,,,,52.8,,,percent of total billed charges,,,32.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,31.15,,,percent of total billed charges,,,548.68,,,per diem,,,52.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,52.8,,,percent of total billed charges,,,44.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.04,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.62,,,percent of total billed charges,,,42.73,,,percent of total billed charges,,,,,,,,,,,,,,,21.12,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,52.8,,,percent of total billed charges,,,52.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,52.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.22,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,4.6,,,fee schedule,,,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,37.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,31.11,,,percent of total billed charges,,
LEUCOVORIN CALCIUM INJ 100 MG,2500000802,CDM,636,RC,J0640,HCPCS,143955401,NDC,430,EAPG,,outpatient,facility,100,GR,52.8,52.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEUCOVORIN CALCIUM INJ 350 MG,2500000804,CDM,636,RC,J0640,HCPCS,703514501,NDC,,,,inpatient,facility,350,GR,75.04,75.04,6,75.04,,,,,,,,,,,,,,75.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.04,,,percent of total billed charges,,,,,,,,,75.04,,,percent of total billed charges,,,38.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.02,,,percent of total billed charges,,,,,,,,,,,,,,,75.04,,,percent of total billed charges,,,63.78,,,percent of total billed charges,,,,,,,,,,,,,,,75.04,,,percent of total billed charges,,,39.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,75.04,,,percent of total billed charges,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,75.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,75.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.21,,,percent of total billed charges,,
LEUCOVORIN CALCIUM INJ 350 MG,2500000804,CDM,636,RC,J0640,HCPCS,703514501,NDC,,,,outpatient,facility,350,GR,75.04,75.04,1.44,548.68,,53.21,,,percent of total billed charges,,,18.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,75.04,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,75.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,27.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.44,,,fee schedule,,,75.04,,,fee schedule,,,75.04,,,percent of total billed charges,,,,,,,,,75.04,,,percent of total billed charges,,,45.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,44.27,,,percent of total billed charges,,,548.68,,,per diem,,,75.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,75.04,,,percent of total billed charges,,,63.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.85,,,percent of total billed charges,,,75.04,,,percent of total billed charges,,,75.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.62,,,percent of total billed charges,,,60.72,,,percent of total billed charges,,,,,,,,,,,,,,,30.02,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,75.04,,,percent of total billed charges,,,75.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,75.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6,,,percent of total billed charges,,,75.04,,,percent of total billed charges,,,,,,,,,,,,,,,75.04,,,percent of total billed charges,,,75.04,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,4.6,,,fee schedule,,,75.04,,,percent of total billed charges,,,75.04,,,percent of total billed charges,,,75.04,,,percent of total billed charges,,,,,,,,,52.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,44.21,,,percent of total billed charges,,
LEUCOVORIN CALCIUM INJ 350 MG,2500000804,CDM,636,RC,J0640,HCPCS,703514501,NDC,430,EAPG,,outpatient,facility,350,GR,75.04,75.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEUCOVORIN CALCIUM INJ 200 MG,2500000805,CDM,636,RC,J0640,HCPCS,6745752920,NDC,,,,inpatient,facility,200,GR,158.4,158.4,12.67,158.4,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,158.4,,,percent of total billed charges,,,80.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.04,,,percent of total billed charges,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,134.64,,,percent of total billed charges,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,84.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,12.67,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.33,,,percent of total billed charges,,
LEUCOVORIN CALCIUM INJ 200 MG,2500000805,CDM,636,RC,J0640,HCPCS,6745752920,NDC,,,,outpatient,facility,200,GR,158.4,158.4,1.44,548.68,,112.32,,,percent of total billed charges,,,38.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,158.4,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,57.97,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.44,,,fee schedule,,,158.4,,,fee schedule,,,158.4,,,percent of total billed charges,,,,,,,,,158.4,,,percent of total billed charges,,,97.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,93.46,,,percent of total billed charges,,,548.68,,,per diem,,,158.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,158.4,,,percent of total billed charges,,,134.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,84.13,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.86,,,percent of total billed charges,,,128.18,,,percent of total billed charges,,,,,,,,,,,,,,,63.36,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,158.4,,,percent of total billed charges,,,158.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,158.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.67,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,4.6,,,fee schedule,,,158.4,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,,,,,,,111.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,93.33,,,percent of total billed charges,,
LEUCOVORIN CALCIUM INJ 200 MG,2500000805,CDM,636,RC,J0640,HCPCS,6745752920,NDC,430,EAPG,,outpatient,facility,200,GR,158.4,158.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEPIVACAINE HCL INJ 30 ML,2500000812,CDM,636,RC,J0670,HCPCS,409104130,NDC,,,,inpatient,facility,30,UN,18.65,18.65,1.49,18.65,,,,,,,,,,,,,,18.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.65,,,percent of total billed charges,,,,,,,,,18.65,,,percent of total billed charges,,,9.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.19,,,percent of total billed charges,,,,,,,,,,,,,,,18.65,,,percent of total billed charges,,,15.85,,,percent of total billed charges,,,,,,,,,,,,,,,18.65,,,percent of total billed charges,,,9.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,18.65,,,percent of total billed charges,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,18.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.99,,,percent of total billed charges,,
MEPIVACAINE HCL INJ 30 ML,2500000812,CDM,636,RC,J0670,HCPCS,409104130,NDC,,,,outpatient,facility,30,UN,18.65,18.65,1.49,548.68,,13.22,,,percent of total billed charges,,,4.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,18.65,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,18.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.83,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,18.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,18.65,,,fee schedule,,,18.65,,,percent of total billed charges,,,,,,,,,18.65,,,percent of total billed charges,,,11.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,11,,,percent of total billed charges,,,548.68,,,per diem,,,18.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,18.65,,,percent of total billed charges,,,15.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.91,,,percent of total billed charges,,,18.65,,,percent of total billed charges,,,18.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.58,,,percent of total billed charges,,,15.09,,,percent of total billed charges,,,,,,,,,,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,18.65,,,percent of total billed charges,,,18.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.49,,,percent of total billed charges,,,18.65,,,percent of total billed charges,,,,,,,,,,,,,,,18.65,,,percent of total billed charges,,,18.65,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.51,,,fee schedule,,,18.65,,,percent of total billed charges,,,18.65,,,percent of total billed charges,,,18.65,,,percent of total billed charges,,,,,,,,,13.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.99,,,percent of total billed charges,,
MEPIVACAINE HCL INJ 30 ML,2500000812,CDM,636,RC,J0670,HCPCS,409104130,NDC,496,EAPG,,outpatient,facility,30,UN,18.65,18.65,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFAZOLIN  SOD INJ  500  MG,2500000822,CDM,636,RC,J0690,HCPCS,4456770625,NDC,,,,inpatient,facility,500,GR,6.34,6.34,0.51,6.34,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,6.34,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,5.39,,,percent of total billed charges,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.74,,,percent of total billed charges,,
CEFAZOLIN  SOD INJ  500  MG,2500000822,CDM,636,RC,J0690,HCPCS,4456770625,NDC,,,,outpatient,facility,500,GR,6.34,6.34,0.51,548.68,,4.5,,,percent of total billed charges,,,1.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.34,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.32,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.71,,,fee schedule,,,6.34,,,fee schedule,,,6.34,,,percent of total billed charges,,,,,,,,,6.34,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,3.74,,,percent of total billed charges,,,548.68,,,per diem,,,6.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.34,,,percent of total billed charges,,,5.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,5.13,,,percent of total billed charges,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6.34,,,percent of total billed charges,,,6.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.51,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,4.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.74,,,percent of total billed charges,,
CEFAZOLIN  SOD INJ  500  MG,2500000822,CDM,636,RC,J0690,HCPCS,4456770625,NDC,496,EAPG,,outpatient,facility,500,GR,6.34,6.34,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFAZOLIN  SOD 1 GM INJ,2500000824,CDM,636,RC,J0690,HCPCS,6050561425,NDC,,,,inpatient,facility,100,GR,8.61,8.61,0.69,8.61,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,8.61,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,7.32,,,percent of total billed charges,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,4.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.07,,,percent of total billed charges,,
CEFAZOLIN  SOD 1 GM INJ,2500000824,CDM,636,RC,J0690,HCPCS,6050561425,NDC,,,,outpatient,facility,100,GR,8.61,8.61,0.69,548.68,,6.11,,,percent of total billed charges,,,2.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.61,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.15,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.71,,,fee schedule,,,8.61,,,fee schedule,,,8.61,,,percent of total billed charges,,,,,,,,,8.61,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,5.08,,,percent of total billed charges,,,548.68,,,per diem,,,8.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.61,,,percent of total billed charges,,,7.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.57,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,6.97,,,percent of total billed charges,,,,,,,,,,,,,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8.61,,,percent of total billed charges,,,8.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.69,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,6.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.07,,,percent of total billed charges,,
CEFAZOLIN  SOD 1 GM INJ,2500000824,CDM,636,RC,J0690,HCPCS,6050561425,NDC,496,EAPG,,outpatient,facility,100,GR,8.61,8.61,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFAZOLIN 2 GM/100ML NS PRMX,2500000825,CDM,636,RC,J0690,HCPCS,6050561425,NDC,,,,inpatient,facility,100,GR,8.61,8.61,0.69,8.61,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,8.61,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,7.32,,,percent of total billed charges,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,4.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.07,,,percent of total billed charges,,
CEFAZOLIN 2 GM/100ML NS PRMX,2500000825,CDM,636,RC,J0690,HCPCS,6050561425,NDC,,,,outpatient,facility,100,GR,8.61,8.61,0.69,548.68,,6.11,,,percent of total billed charges,,,2.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.61,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.15,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.71,,,fee schedule,,,8.61,,,fee schedule,,,8.61,,,percent of total billed charges,,,,,,,,,8.61,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,5.08,,,percent of total billed charges,,,548.68,,,per diem,,,8.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.61,,,percent of total billed charges,,,7.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.57,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,6.97,,,percent of total billed charges,,,,,,,,,,,,,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8.61,,,percent of total billed charges,,,8.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.69,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,6.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.07,,,percent of total billed charges,,
CEFAZOLIN 2 GM/100ML NS PRMX,2500000825,CDM,636,RC,J0690,HCPCS,6050561425,NDC,496,EAPG,,outpatient,facility,100,GR,8.61,8.61,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFAZOLIN 2 GM/50 ML D5W PRMX,2500000827,CDM,636,RC,J0690,HCPCS,264310511,NDC,,,,inpatient,facility,50,GR,48.71,48.71,3.9,48.71,,,,,,,,,,,,,,48.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.71,,,percent of total billed charges,,,,,,,,,48.71,,,percent of total billed charges,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.23,,,percent of total billed charges,,,,,,,,,,,,,,,48.71,,,percent of total billed charges,,,41.4,,,percent of total billed charges,,,,,,,,,,,,,,,48.71,,,percent of total billed charges,,,25.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,48.71,,,percent of total billed charges,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,48.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.7,,,percent of total billed charges,,
CEFAZOLIN 2 GM/50 ML D5W PRMX,2500000827,CDM,636,RC,J0690,HCPCS,264310511,NDC,,,,outpatient,facility,50,GR,48.71,48.71,0.71,548.68,,34.54,,,percent of total billed charges,,,11.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,48.71,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,48.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,17.83,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.71,,,fee schedule,,,48.71,,,fee schedule,,,48.71,,,percent of total billed charges,,,,,,,,,48.71,,,percent of total billed charges,,,29.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,28.74,,,percent of total billed charges,,,548.68,,,per diem,,,48.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,48.71,,,percent of total billed charges,,,41.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.87,,,percent of total billed charges,,,48.71,,,percent of total billed charges,,,48.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.86,,,percent of total billed charges,,,39.42,,,percent of total billed charges,,,,,,,,,,,,,,,19.48,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,48.71,,,percent of total billed charges,,,48.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,48.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.9,,,percent of total billed charges,,,48.71,,,percent of total billed charges,,,,,,,,,,,,,,,48.71,,,percent of total billed charges,,,48.71,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,48.71,,,percent of total billed charges,,,48.71,,,percent of total billed charges,,,48.71,,,percent of total billed charges,,,,,,,,,34.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,28.7,,,percent of total billed charges,,
CEFAZOLIN 2 GM/50 ML D5W PRMX,2500000827,CDM,636,RC,J0690,HCPCS,264310511,NDC,496,EAPG,,outpatient,facility,50,GR,48.71,48.71,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFAZOLIN 3 GM/100ML NS PRMX,2500000829,CDM,636,RC,J0690,HCPCS,6050561425,NDC,,,,inpatient,facility,100,GR,8.61,8.61,0.69,8.61,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,8.61,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,7.32,,,percent of total billed charges,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,4.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.07,,,percent of total billed charges,,
CEFAZOLIN 3 GM/100ML NS PRMX,2500000829,CDM,636,RC,J0690,HCPCS,6050561425,NDC,,,,outpatient,facility,100,GR,8.61,8.61,0.69,548.68,,6.11,,,percent of total billed charges,,,2.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.61,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.15,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.71,,,fee schedule,,,8.61,,,fee schedule,,,8.61,,,percent of total billed charges,,,,,,,,,8.61,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,5.08,,,percent of total billed charges,,,548.68,,,per diem,,,8.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.61,,,percent of total billed charges,,,7.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.57,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,6.97,,,percent of total billed charges,,,,,,,,,,,,,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8.61,,,percent of total billed charges,,,8.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.69,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,6.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.07,,,percent of total billed charges,,
CEFAZOLIN 3 GM/100ML NS PRMX,2500000829,CDM,636,RC,J0690,HCPCS,6050561425,NDC,496,EAPG,,outpatient,facility,100,GR,8.61,8.61,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFOXITIN  SOD INJ 1 GM,2500000830,CDM,636,RC,J0694,HCPCS,6332334125,NDC,,,,inpatient,facility,1,UN,23.07,23.07,1.85,23.07,,,,,,,,,,,,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.07,,,percent of total billed charges,,,,,,,,,23.07,,,percent of total billed charges,,,11.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.84,,,percent of total billed charges,,,,,,,,,,,,,,,23.07,,,percent of total billed charges,,,19.61,,,percent of total billed charges,,,,,,,,,,,,,,,23.07,,,percent of total billed charges,,,12.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.59,,,percent of total billed charges,,
CEFOXITIN  SOD INJ 1 GM,2500000830,CDM,636,RC,J0694,HCPCS,6332334125,NDC,,,,outpatient,facility,1,UN,23.07,23.07,1.85,548.68,,16.36,,,percent of total billed charges,,,5.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,23.07,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.01,,,fee schedule,,,23.07,,,fee schedule,,,23.07,,,percent of total billed charges,,,,,,,,,23.07,,,percent of total billed charges,,,14.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,13.61,,,percent of total billed charges,,,548.68,,,per diem,,,23.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,23.07,,,percent of total billed charges,,,19.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.25,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.56,,,percent of total billed charges,,,18.67,,,percent of total billed charges,,,,,,,,,,,,,,,9.23,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,23.07,,,percent of total billed charges,,,23.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.85,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,23.07,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,4.65,,,fee schedule,,,23.07,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,,,,,,,16.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.59,,,percent of total billed charges,,
CEFOXITIN  SOD INJ 1 GM,2500000830,CDM,636,RC,J0694,HCPCS,6332334125,NDC,496,EAPG,,outpatient,facility,1,UN,23.07,23.07,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFOXITIN  SOD INJ  2 GM,2500000832,CDM,636,RC,J0694,HCPCS,6332334225,NDC,,,,inpatient,facility,2,UN,46.07,46.07,3.69,46.07,,,,,,,,,,,,,,46.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.07,,,percent of total billed charges,,,,,,,,,46.07,,,percent of total billed charges,,,23.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.64,,,percent of total billed charges,,,,,,,,,,,,,,,46.07,,,percent of total billed charges,,,39.16,,,percent of total billed charges,,,,,,,,,,,,,,,46.07,,,percent of total billed charges,,,24.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,46.07,,,percent of total billed charges,,,,,,,,,,,,,,,3.69,,,percent of total billed charges,,,46.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.14,,,percent of total billed charges,,
CEFOXITIN  SOD INJ  2 GM,2500000832,CDM,636,RC,J0694,HCPCS,6332334225,NDC,,,,outpatient,facility,2,UN,46.07,46.07,3.69,548.68,,32.67,,,percent of total billed charges,,,11.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,46.07,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,46.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,16.86,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.01,,,fee schedule,,,46.07,,,fee schedule,,,46.07,,,percent of total billed charges,,,,,,,,,46.07,,,percent of total billed charges,,,28.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,27.18,,,percent of total billed charges,,,548.68,,,per diem,,,46.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,46.07,,,percent of total billed charges,,,39.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.47,,,percent of total billed charges,,,46.07,,,percent of total billed charges,,,46.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.08,,,percent of total billed charges,,,37.28,,,percent of total billed charges,,,,,,,,,,,,,,,18.43,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,46.07,,,percent of total billed charges,,,46.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.69,,,percent of total billed charges,,,46.07,,,percent of total billed charges,,,,,,,,,,,,,,,46.07,,,percent of total billed charges,,,46.07,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,4.65,,,fee schedule,,,46.07,,,percent of total billed charges,,,46.07,,,percent of total billed charges,,,46.07,,,percent of total billed charges,,,,,,,,,32.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,27.14,,,percent of total billed charges,,
CEFOXITIN  SOD INJ  2 GM,2500000832,CDM,636,RC,J0694,HCPCS,6332334225,NDC,496,EAPG,,outpatient,facility,2,UN,46.07,46.07,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTRIAXONE  SOD INJ  250 MG,2500000850,CDM,636,RC,J0696,HCPCS,6050561511,NDC,,,,inpatient,facility,250,UN,48.9,48.9,3.91,48.9,,,,,,,,,,,,,,48.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,percent of total billed charges,,,,,,,,,48.9,,,percent of total billed charges,,,24.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.34,,,percent of total billed charges,,,,,,,,,,,,,,,48.9,,,percent of total billed charges,,,41.56,,,percent of total billed charges,,,,,,,,,,,,,,,48.9,,,percent of total billed charges,,,25.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,percent of total billed charges,,,,,,,,,,,,,,,3.91,,,percent of total billed charges,,,48.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.81,,,percent of total billed charges,,
CEFTRIAXONE  SOD INJ  250 MG,2500000850,CDM,636,RC,J0696,HCPCS,6050561511,NDC,,,,outpatient,facility,250,UN,48.9,48.9,0.47,548.68,,34.67,,,percent of total billed charges,,,11.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,48.9,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,17.9,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.07,,,fee schedule,,,48.9,,,fee schedule,,,48.9,,,percent of total billed charges,,,,,,,,,48.9,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,28.85,,,percent of total billed charges,,,548.68,,,per diem,,,48.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,48.9,,,percent of total billed charges,,,41.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.97,,,percent of total billed charges,,,48.9,,,percent of total billed charges,,,48.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.99,,,percent of total billed charges,,,39.57,,,percent of total billed charges,,,,,,,,,,,,,,,19.56,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,48.9,,,percent of total billed charges,,,48.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,48.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.91,,,percent of total billed charges,,,48.9,,,percent of total billed charges,,,,,,,,,,,,,,,48.9,,,percent of total billed charges,,,48.9,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.47,,,fee schedule,,,48.9,,,percent of total billed charges,,,48.9,,,percent of total billed charges,,,48.9,,,percent of total billed charges,,,,,,,,,34.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,28.81,,,percent of total billed charges,,
CEFTRIAXONE  SOD INJ  250 MG,2500000850,CDM,636,RC,J0696,HCPCS,6050561511,NDC,496,EAPG,,outpatient,facility,250,UN,48.9,48.9,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTRIAXONE  SOD INJ 500 MG,2500000852,CDM,636,RC,J0696,HCPCS,6050561521,NDC,,,,inpatient,facility,500,UN,88.61,88.61,7.09,88.61,,,,,,,,,,,,,,88.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.61,,,percent of total billed charges,,,,,,,,,88.61,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.17,,,percent of total billed charges,,,,,,,,,,,,,,,88.61,,,percent of total billed charges,,,75.32,,,percent of total billed charges,,,,,,,,,,,,,,,88.61,,,percent of total billed charges,,,47.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,88.61,,,percent of total billed charges,,,,,,,,,,,,,,,7.09,,,percent of total billed charges,,,88.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,88.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.21,,,percent of total billed charges,,
CEFTRIAXONE  SOD INJ 500 MG,2500000852,CDM,636,RC,J0696,HCPCS,6050561521,NDC,,,,outpatient,facility,500,UN,88.61,88.61,0.47,548.68,,62.83,,,percent of total billed charges,,,21.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,88.61,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,88.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,32.43,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.07,,,fee schedule,,,88.61,,,fee schedule,,,88.61,,,percent of total billed charges,,,,,,,,,88.61,,,percent of total billed charges,,,54.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,52.28,,,percent of total billed charges,,,548.68,,,per diem,,,88.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,88.61,,,percent of total billed charges,,,75.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.06,,,percent of total billed charges,,,88.61,,,percent of total billed charges,,,88.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.78,,,percent of total billed charges,,,71.7,,,percent of total billed charges,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,88.61,,,percent of total billed charges,,,88.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,88.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.09,,,percent of total billed charges,,,88.61,,,percent of total billed charges,,,,,,,,,,,,,,,88.61,,,percent of total billed charges,,,88.61,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.47,,,fee schedule,,,88.61,,,percent of total billed charges,,,88.61,,,percent of total billed charges,,,88.61,,,percent of total billed charges,,,,,,,,,62.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,52.21,,,percent of total billed charges,,
CEFTRIAXONE  SOD INJ 500 MG,2500000852,CDM,636,RC,J0696,HCPCS,6050561521,NDC,496,EAPG,,outpatient,facility,500,UN,88.61,88.61,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTRIAXONE  SOD  INJ 1GM,2500000854,CDM,636,RC,J0696,HCPCS,4456770125,NDC,,,,inpatient,facility,1,UN,11.88,11.88,0.95,11.88,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,11.88,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,6.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7,,,percent of total billed charges,,
CEFTRIAXONE  SOD  INJ 1GM,2500000854,CDM,636,RC,J0696,HCPCS,4456770125,NDC,,,,outpatient,facility,1,UN,11.88,11.88,0.47,548.68,,8.42,,,percent of total billed charges,,,2.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,11.88,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.35,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.07,,,fee schedule,,,11.88,,,fee schedule,,,11.88,,,percent of total billed charges,,,,,,,,,11.88,,,percent of total billed charges,,,7.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.01,,,percent of total billed charges,,,548.68,,,per diem,,,11.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11.88,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.31,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.01,,,percent of total billed charges,,,9.61,,,percent of total billed charges,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11.88,,,percent of total billed charges,,,11.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.95,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.47,,,fee schedule,,,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,8.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7,,,percent of total billed charges,,
CEFTRIAXONE  SOD  INJ 1GM,2500000854,CDM,636,RC,J0696,HCPCS,4456770125,NDC,496,EAPG,,outpatient,facility,1,UN,11.88,11.88,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTRIAXONE  SOD  INJ 2GM,2500000856,CDM,636,RC,J0696,HCPCS,143985625,NDC,,,,inpatient,facility,2,UN,9.9,9.9,0.79,9.9,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,5.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,5.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.83,,,percent of total billed charges,,
CEFTRIAXONE  SOD  INJ 2GM,2500000856,CDM,636,RC,J0696,HCPCS,143985625,NDC,,,,outpatient,facility,2,UN,9.9,9.9,0.47,548.68,,7.02,,,percent of total billed charges,,,2.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.9,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.62,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.07,,,fee schedule,,,9.9,,,fee schedule,,,9.9,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,5.84,,,percent of total billed charges,,,548.68,,,per diem,,,9.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.9,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.26,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.68,,,percent of total billed charges,,,8.01,,,percent of total billed charges,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9.9,,,percent of total billed charges,,,9.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.79,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.47,,,fee schedule,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,6.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.83,,,percent of total billed charges,,
CEFTRIAXONE  SOD  INJ 2GM,2500000856,CDM,636,RC,J0696,HCPCS,143985625,NDC,496,EAPG,,outpatient,facility,2,UN,9.9,9.9,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTAROLINE 400 MG INJ,2500000907,CDM,636,RC,J0712,HCPCS,456040010,NDC,,,,inpatient,facility,400,GR,770.62,770.62,61.65,770.62,,,,,,,,,,,,,,770.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,770.62,,,percent of total billed charges,,,,,,,,,770.62,,,percent of total billed charges,,,393.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,656.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462.37,,,percent of total billed charges,,,,,,,,,,,,,,,770.62,,,percent of total billed charges,,,655.03,,,percent of total billed charges,,,,,,,,,,,,,,,770.62,,,percent of total billed charges,,,409.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,770.62,,,percent of total billed charges,,,,,,,,,,,,,,,61.65,,,percent of total billed charges,,,770.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,770.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,454.05,,,percent of total billed charges,,
CEFTAROLINE 400 MG INJ,2500000907,CDM,636,RC,J0712,HCPCS,456040010,NDC,,,,outpatient,facility,400,GR,770.62,770.62,2.55,770.62,,546.45,,,percent of total billed charges,,,,,,,,,770.62,,,percent of total billed charges,,,5.23,,,fee schedule,,,4.95,,,fee schedule,,,,,,,,,4.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,770.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,770.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,770.62,,,fee schedule,,,770.62,,,percent of total billed charges,,,,,,,,,770.62,,,percent of total billed charges,,,472.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,549.07,,,percent of total billed charges,,,,,,,,,,,,,,,3.84,,,fee schedule,,,3.84,,,fee schedule,,,3.84,,,fee schedule,,,,,,,,,454.67,,,percent of total billed charges,,,548.68,,,per diem,,,770.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,770.62,,,percent of total billed charges,,,655.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,409.28,,,percent of total billed charges,,,770.62,,,percent of total billed charges,,,770.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,519.86,,,percent of total billed charges,,,623.59,,,percent of total billed charges,,,,,,,,,,,,,,,308.25,,,percent of total billed charges,,,,,,,,,9.19,,,fee schedule,,,6.61,,,fee schedule,,,,,,,,,770.62,,,percent of total billed charges,,,,,,,,,,,,,,,61.65,,,percent of total billed charges,,,770.62,,,percent of total billed charges,,,,,,,,,,,,,,,770.62,,,percent of total billed charges,,,770.62,,,percent of total billed charges,,,,,,,,,3.93,,,fee schedule,,,,,,,,,,,,,,,3.41,,,fee schedule,,,4.54,,,fee schedule,,,2.55,,,fee schedule,,,4.18,,,fee schedule,,,770.62,,,percent of total billed charges,,,770.62,,,percent of total billed charges,,,770.62,,,percent of total billed charges,,,,,,,,,540.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,454.05,,,percent of total billed charges,,
CEFTAROLINE 400 MG INJ,2500000907,CDM,636,RC,J0712,HCPCS,456040010,NDC,1824,APC,,outpatient,facility,400,GR,770.62,770.62,3.79,282.05,,,,,,,,4.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,fee schedule,,,,,,,,,282.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,,,,,,,4.15,,,fee schedule,,,4.15,,,fee schedule,,,,,,,,,3.95,,,fee schedule,,,3.95,,,fee schedule,,,4.15,,,fee schedule,,,,,,,,,,,,,,,5.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.79,,,fee schedule,,,4.23,,,fee schedule,,,4.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,3.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,4.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,4.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,3.95,,,fee schedule,,,3.95,,,fee schedule,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,3.95,,,fee schedule,,,4.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,,,,,,,4.11,,,fee schedule,,,3.95,,,fee schedule,,,,,,,,,3.95,,,fee schedule,,,,,,,,,3.95,,,fee schedule,,,4.15,,,fee schedule,,,,,,,,
CEFTAROLINE 400 MG INJ,2500000907,CDM,636,RC,J0712,HCPCS,456040010,NDC,437,EAPG,,outpatient,facility,400,GR,770.62,770.62,156.28,235.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.98,,,fee schedule,,,156.28,,,fee schedule,,,209.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTAROLINE 600 MG INJ,2500000908,CDM,636,RC,J0712,HCPCS,456060010,NDC,,,,inpatient,facility,600,GR,809.16,809.16,64.73,809.16,,,,,,,,,,,,,,809.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,809.16,,,percent of total billed charges,,,,,,,,,809.16,,,percent of total billed charges,,,413.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,689.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,485.5,,,percent of total billed charges,,,,,,,,,,,,,,,809.16,,,percent of total billed charges,,,687.79,,,percent of total billed charges,,,,,,,,,,,,,,,809.16,,,percent of total billed charges,,,429.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,809.16,,,percent of total billed charges,,,,,,,,,,,,,,,64.73,,,percent of total billed charges,,,809.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,809.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.76,,,percent of total billed charges,,
CEFTAROLINE 600 MG INJ,2500000908,CDM,636,RC,J0712,HCPCS,456060010,NDC,,,,outpatient,facility,600,GR,809.16,809.16,2.55,809.16,,573.78,,,percent of total billed charges,,,,,,,,,809.16,,,percent of total billed charges,,,5.23,,,fee schedule,,,4.95,,,fee schedule,,,,,,,,,4.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,809.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,809.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,809.16,,,fee schedule,,,809.16,,,percent of total billed charges,,,,,,,,,809.16,,,percent of total billed charges,,,495.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,576.53,,,percent of total billed charges,,,,,,,,,,,,,,,3.84,,,fee schedule,,,3.84,,,fee schedule,,,3.84,,,fee schedule,,,,,,,,,477.4,,,percent of total billed charges,,,548.68,,,per diem,,,809.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,809.16,,,percent of total billed charges,,,687.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,429.74,,,percent of total billed charges,,,809.16,,,percent of total billed charges,,,809.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,545.86,,,percent of total billed charges,,,654.77,,,percent of total billed charges,,,,,,,,,,,,,,,323.66,,,percent of total billed charges,,,,,,,,,9.19,,,fee schedule,,,6.61,,,fee schedule,,,,,,,,,809.16,,,percent of total billed charges,,,,,,,,,,,,,,,64.73,,,percent of total billed charges,,,809.16,,,percent of total billed charges,,,,,,,,,,,,,,,809.16,,,percent of total billed charges,,,809.16,,,percent of total billed charges,,,,,,,,,3.93,,,fee schedule,,,,,,,,,,,,,,,3.41,,,fee schedule,,,4.54,,,fee schedule,,,2.55,,,fee schedule,,,4.18,,,fee schedule,,,809.16,,,percent of total billed charges,,,809.16,,,percent of total billed charges,,,809.16,,,percent of total billed charges,,,,,,,,,567.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,476.76,,,percent of total billed charges,,
CEFTAROLINE 600 MG INJ,2500000908,CDM,636,RC,J0712,HCPCS,456060010,NDC,1824,APC,,outpatient,facility,600,GR,809.16,809.16,3.79,296.15,,,,,,,,4.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,fee schedule,,,,,,,,,296.15,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,,,,,,,4.15,,,fee schedule,,,4.15,,,fee schedule,,,,,,,,,3.95,,,fee schedule,,,3.95,,,fee schedule,,,4.15,,,fee schedule,,,,,,,,,,,,,,,5.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.79,,,fee schedule,,,4.23,,,fee schedule,,,4.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,3.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,4.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,4.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,3.95,,,fee schedule,,,3.95,,,fee schedule,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,3.95,,,fee schedule,,,4.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.95,,,fee schedule,,,,,,,,,,,,,,,4.11,,,fee schedule,,,3.95,,,fee schedule,,,,,,,,,3.95,,,fee schedule,,,,,,,,,3.95,,,fee schedule,,,4.15,,,fee schedule,,,,,,,,
CEFTAROLINE 600 MG INJ,2500000908,CDM,636,RC,J0712,HCPCS,456060010,NDC,437,EAPG,,outpatient,facility,600,GR,809.16,809.16,156.28,235.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.98,,,fee schedule,,,156.28,,,fee schedule,,,209.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTAZIDIME INJ 1GM,2500000912,CDM,636,RC,J0713,HCPCS,4456723525,NDC,,,,inpatient,facility,1,UN,17.82,17.82,1.43,17.82,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,,,,,,,17.82,,,percent of total billed charges,,,9.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.69,,,percent of total billed charges,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,15.15,,,percent of total billed charges,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,9.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.5,,,percent of total billed charges,,
CEFTAZIDIME INJ 1GM,2500000912,CDM,636,RC,J0713,HCPCS,4456723525,NDC,,,,outpatient,facility,1,UN,17.82,17.82,1.43,548.68,,12.64,,,percent of total billed charges,,,4.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,17.82,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.52,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,17.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,17.82,,,fee schedule,,,17.82,,,percent of total billed charges,,,,,,,,,17.82,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,10.51,,,percent of total billed charges,,,548.68,,,per diem,,,17.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,17.82,,,percent of total billed charges,,,15.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.46,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.02,,,percent of total billed charges,,,14.42,,,percent of total billed charges,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17.82,,,percent of total billed charges,,,17.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.43,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.68,,,fee schedule,,,17.82,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,,,,,,,12.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.5,,,percent of total billed charges,,
CEFTAZIDIME INJ 1GM,2500000912,CDM,636,RC,J0713,HCPCS,4456723525,NDC,496,EAPG,,outpatient,facility,1,UN,17.82,17.82,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTAZIDIME INJ 2GM,2500000914,CDM,636,RC,J0713,HCPCS,409508411,NDC,,,,inpatient,facility,2,UN,31.52,31.52,2.52,31.52,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,,,,,,,31.52,,,percent of total billed charges,,,16.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.91,,,percent of total billed charges,,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,26.79,,,percent of total billed charges,,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.57,,,percent of total billed charges,,
CEFTAZIDIME INJ 2GM,2500000914,CDM,636,RC,J0713,HCPCS,409508411,NDC,,,,outpatient,facility,2,UN,31.52,31.52,1.68,548.68,,22.35,,,percent of total billed charges,,,7.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,31.52,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.54,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,31.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,31.52,,,fee schedule,,,31.52,,,percent of total billed charges,,,,,,,,,31.52,,,percent of total billed charges,,,19.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,18.6,,,percent of total billed charges,,,548.68,,,per diem,,,31.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,31.52,,,percent of total billed charges,,,26.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.74,,,percent of total billed charges,,,31.52,,,percent of total billed charges,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.26,,,percent of total billed charges,,,25.51,,,percent of total billed charges,,,,,,,,,,,,,,,12.61,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,31.52,,,percent of total billed charges,,,31.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.52,,,percent of total billed charges,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.68,,,fee schedule,,,31.52,,,percent of total billed charges,,,31.52,,,percent of total billed charges,,,31.52,,,percent of total billed charges,,,,,,,,,22.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.57,,,percent of total billed charges,,
CEFTAZIDIME INJ 2GM,2500000914,CDM,636,RC,J0713,HCPCS,409508411,NDC,496,EAPG,,outpatient,facility,2,UN,31.52,31.52,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLONIDINE HCL EPIDURAL 1 MG,2500000960,CDM,636,RC,J0735,HCPCS,6745721810,NDC,,,,inpatient,facility,10,UN,124.11,124.11,9.93,124.11,,,,,,,,,,,,,,124.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.11,,,percent of total billed charges,,,,,,,,,124.11,,,percent of total billed charges,,,63.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.47,,,percent of total billed charges,,,,,,,,,,,,,,,124.11,,,percent of total billed charges,,,105.49,,,percent of total billed charges,,,,,,,,,,,,,,,124.11,,,percent of total billed charges,,,65.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,124.11,,,percent of total billed charges,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,124.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,124.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.13,,,percent of total billed charges,,
CLONIDINE HCL EPIDURAL 1 MG,2500000960,CDM,636,RC,J0735,HCPCS,6745721810,NDC,,,,outpatient,facility,10,UN,124.11,124.11,9.93,548.68,,88.01,,,percent of total billed charges,,,30.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,124.11,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,124.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,45.42,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,124.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,124.11,,,fee schedule,,,124.11,,,percent of total billed charges,,,,,,,,,124.11,,,percent of total billed charges,,,76.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,73.22,,,percent of total billed charges,,,548.68,,,per diem,,,124.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,124.11,,,percent of total billed charges,,,105.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.91,,,percent of total billed charges,,,124.11,,,percent of total billed charges,,,124.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.72,,,percent of total billed charges,,,100.43,,,percent of total billed charges,,,,,,,,,,,,,,,49.64,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,124.11,,,percent of total billed charges,,,124.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,124.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.93,,,percent of total billed charges,,,124.11,,,percent of total billed charges,,,,,,,,,,,,,,,124.11,,,percent of total billed charges,,,124.11,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,18.02,,,fee schedule,,,124.11,,,percent of total billed charges,,,124.11,,,percent of total billed charges,,,124.11,,,percent of total billed charges,,,,,,,,,87.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,73.13,,,percent of total billed charges,,
CLONIDINE HCL EPIDURAL 1 MG,2500000960,CDM,636,RC,J0735,HCPCS,6745721810,NDC,999,EAPG,,outpatient,facility,10,UN,124.11,124.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROCHLORPERAZINE INJ 10 MG,2500001020,CDM,636,RC,J0780,HCPCS,1478970002,NDC,,,,inpatient,facility,2,ML,59.4,59.4,4.75,59.4,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,30.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,31.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35,,,percent of total billed charges,,
PROCHLORPERAZINE INJ 10 MG,2500001020,CDM,636,RC,J0780,HCPCS,1478970002,NDC,,,,outpatient,facility,2,ML,59.4,59.4,2.21,548.68,,42.12,,,percent of total billed charges,,,14.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,59.4,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,21.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.21,,,fee schedule,,,59.4,,,fee schedule,,,59.4,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,36.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,35.05,,,percent of total billed charges,,,548.68,,,per diem,,,59.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,59.4,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.55,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.07,,,percent of total billed charges,,,48.07,,,percent of total billed charges,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,59.4,,,percent of total billed charges,,,59.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,59.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.75,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.78,,,fee schedule,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,41.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,35,,,percent of total billed charges,,
PROCHLORPERAZINE INJ 10 MG,2500001020,CDM,636,RC,J0780,HCPCS,1478970002,NDC,496,EAPG,,outpatient,facility,2,ML,59.4,59.4,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COSYNTROPIN INJ PER 0.25 MG,2500001050,CDM,636,RC,J0834,HCPCS,548590000,NDC,,,,inpatient,facility,1,UN,351.71,351.71,28.14,351.71,,,,,,,,,,,,,,351.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,351.71,,,percent of total billed charges,,,,,,,,,351.71,,,percent of total billed charges,,,179.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.03,,,percent of total billed charges,,,,,,,,,,,,,,,351.71,,,percent of total billed charges,,,298.95,,,percent of total billed charges,,,,,,,,,,,,,,,351.71,,,percent of total billed charges,,,186.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,351.71,,,percent of total billed charges,,,,,,,,,,,,,,,28.14,,,percent of total billed charges,,,351.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,351.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.23,,,percent of total billed charges,,
COSYNTROPIN INJ PER 0.25 MG,2500001050,CDM,636,RC,J0834,HCPCS,548590000,NDC,,,,outpatient,facility,1,UN,351.71,351.71,22.55,548.68,,249.4,,,percent of total billed charges,,,85.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,351.71,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,351.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,128.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,79.53,,,fee schedule,,,351.71,,,fee schedule,,,351.71,,,percent of total billed charges,,,,,,,,,351.71,,,percent of total billed charges,,,215.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,207.51,,,percent of total billed charges,,,548.68,,,per diem,,,351.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,351.71,,,percent of total billed charges,,,298.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186.79,,,percent of total billed charges,,,351.71,,,percent of total billed charges,,,351.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.26,,,percent of total billed charges,,,284.6,,,percent of total billed charges,,,,,,,,,,,,,,,140.68,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,351.71,,,percent of total billed charges,,,351.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,351.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.14,,,percent of total billed charges,,,351.71,,,percent of total billed charges,,,,,,,,,,,,,,,351.71,,,percent of total billed charges,,,351.71,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,22.55,,,fee schedule,,,351.71,,,percent of total billed charges,,,351.71,,,percent of total billed charges,,,351.71,,,percent of total billed charges,,,,,,,,,246.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,207.23,,,percent of total billed charges,,
COSYNTROPIN INJ PER 0.25 MG,2500001050,CDM,636,RC,J0834,HCPCS,548590000,NDC,435,EAPG,,outpatient,facility,1,UN,351.71,351.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPREDNISOL ACE INJ 40 MG,2500001130,CDM,636,RC,J1010,HCPCS,9307303,NDC,,,,inpatient,facility,1,UN,37.52,37.52,3,37.52,,,,,,,,,,,,,,37.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.52,,,percent of total billed charges,,,,,,,,,37.52,,,percent of total billed charges,,,19.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.51,,,percent of total billed charges,,,,,,,,,,,,,,,37.52,,,percent of total billed charges,,,31.89,,,percent of total billed charges,,,,,,,,,,,,,,,37.52,,,percent of total billed charges,,,19.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,37.52,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,37.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,
METHYLPREDNISOL ACE INJ 40 MG,2500001130,CDM,636,RC,J1010,HCPCS,9307303,NDC,,,,outpatient,facility,1,UN,37.52,37.52,0.14,548.68,,26.61,,,percent of total billed charges,,,,,,,,,37.52,,,percent of total billed charges,,,0.18,,,fee schedule,,,0.17,,,fee schedule,,,,,,,,,0.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,37.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,37.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,37.52,,,fee schedule,,,37.52,,,percent of total billed charges,,,,,,,,,37.52,,,percent of total billed charges,,,23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.73,,,percent of total billed charges,,,,,,,,,,,,,,,20.26,,,percent of total billed charges,,,19.51,,,percent of total billed charges,,,20.64,,,percent of total billed charges,,,,,,,,,22.14,,,percent of total billed charges,,,548.68,,,per diem,,,37.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,37.52,,,percent of total billed charges,,,31.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.93,,,percent of total billed charges,,,37.52,,,percent of total billed charges,,,37.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.31,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,15.01,,,percent of total billed charges,,,,,,,,,13.88,,,percent of total billed charges,,,13.88,,,percent of total billed charges,,,,,,,,,37.52,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,37.52,,,percent of total billed charges,,,,,,,,,,,,,,,37.52,,,percent of total billed charges,,,37.52,,,percent of total billed charges,,,,,,,,,34.9,,,percent of total billed charges,,,,,,,,,,,,,,,34.9,,,percent of total billed charges,,,34.9,,,percent of total billed charges,,,34.9,,,percent of total billed charges,,,0.14,,,fee schedule,,,37.52,,,percent of total billed charges,,,37.52,,,percent of total billed charges,,,37.52,,,percent of total billed charges,,,,,,,,,26.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,22.11,,,percent of total billed charges,,
METHYLPREDNISOL ACE INJ 40 MG,2500001130,CDM,636,RC,J1010,HCPCS,9307303,NDC,790,APC,,outpatient,facility,1,UN,37.52,37.52,0.12,13.73,,,,,,,,0.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,13.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,0.13,,,fee schedule,,,0.13,,,fee schedule,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,0.13,,,fee schedule,,,,,,,,,,,,,,,0.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.13,,,fee schedule,,,0.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,,,,,,,0.12,,,fee schedule,,,,,,,,,0.12,,,fee schedule,,,0.13,,,fee schedule,,,,,,,,
METHYLPREDNISOL ACE INJ 40 MG,2500001130,CDM,636,RC,J1010,HCPCS,9307303,NDC,496,EAPG,,outpatient,facility,1,UN,37.52,37.52,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPREDNISOL ACE INJ 80 MG,2500001140,CDM,636,RC,J1010,HCPCS,7012115745,NDC,,,,inpatient,facility,1,UN,64.61,64.61,5.17,64.61,,,,,,,,,,,,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.61,,,percent of total billed charges,,,,,,,,,64.61,,,percent of total billed charges,,,32.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.77,,,percent of total billed charges,,,,,,,,,,,,,,,64.61,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,,,,,,,,,,,,,64.61,,,percent of total billed charges,,,34.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.07,,,percent of total billed charges,,
METHYLPREDNISOL ACE INJ 80 MG,2500001140,CDM,636,RC,J1010,HCPCS,7012115745,NDC,,,,outpatient,facility,1,UN,64.61,64.61,0.14,548.68,,45.81,,,percent of total billed charges,,,,,,,,,64.61,,,percent of total billed charges,,,0.18,,,fee schedule,,,0.17,,,fee schedule,,,,,,,,,0.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,64.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,64.61,,,fee schedule,,,64.61,,,percent of total billed charges,,,,,,,,,64.61,,,percent of total billed charges,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.03,,,percent of total billed charges,,,,,,,,,,,,,,,34.89,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,35.54,,,percent of total billed charges,,,,,,,,,38.12,,,percent of total billed charges,,,548.68,,,per diem,,,64.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,64.61,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.31,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.59,,,percent of total billed charges,,,52.28,,,percent of total billed charges,,,,,,,,,,,,,,,25.84,,,percent of total billed charges,,,,,,,,,23.91,,,percent of total billed charges,,,23.91,,,percent of total billed charges,,,,,,,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,64.61,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,,,,,,,60.1,,,percent of total billed charges,,,,,,,,,,,,,,,60.1,,,percent of total billed charges,,,60.1,,,percent of total billed charges,,,60.1,,,percent of total billed charges,,,0.14,,,fee schedule,,,64.61,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,,,,,,,45.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,38.07,,,percent of total billed charges,,
METHYLPREDNISOL ACE INJ 80 MG,2500001140,CDM,636,RC,J1010,HCPCS,7012115745,NDC,790,APC,,outpatient,facility,1,UN,64.61,64.61,0.12,23.65,,,,,,,,0.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,23.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,0.13,,,fee schedule,,,0.13,,,fee schedule,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,0.13,,,fee schedule,,,,,,,,,,,,,,,0.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.13,,,fee schedule,,,0.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,fee schedule,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.12,,,fee schedule,,,,,,,,,0.12,,,fee schedule,,,,,,,,,0.12,,,fee schedule,,,0.13,,,fee schedule,,,,,,,,
METHYLPREDNISOL ACE INJ 80 MG,2500001140,CDM,636,RC,J1010,HCPCS,7012115745,NDC,496,EAPG,,outpatient,facility,1,UN,64.61,64.61,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXAMETHASONE  SOD INJ 4MG,2500001221,CDM,636,RC,J1100,HCPCS,641614525,NDC,,,,inpatient,facility,1,ML,3.2,3.2,0.26,3.2,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,3.2,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,
DEXAMETHASONE  SOD INJ 4MG,2500001221,CDM,636,RC,J1100,HCPCS,641614525,NDC,,,,outpatient,facility,1,ML,3.2,3.2,0.1,548.68,,2.27,,,percent of total billed charges,,,0.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.17,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.1,,,fee schedule,,,3.2,,,fee schedule,,,3.2,,,percent of total billed charges,,,,,,,,,3.2,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,1.89,,,percent of total billed charges,,,548.68,,,per diem,,,3.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.2,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3.2,,,percent of total billed charges,,,3.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.12,,,fee schedule,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.89,,,percent of total billed charges,,
DEXAMETHASONE  SOD INJ 4MG,2500001221,CDM,636,RC,J1100,HCPCS,641614525,NDC,496,EAPG,,outpatient,facility,1,ML,3.2,3.2,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXAMETHASONE  SOD INJ 10 MG,2500001225,CDM,636,RC,J1100,HCPCS,6332350601,NDC,,,,inpatient,facility,1,ML,15.12,15.12,1.21,15.12,,,,,,,,,,,,,,15.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.12,,,percent of total billed charges,,,,,,,,,15.12,,,percent of total billed charges,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,15.12,,,percent of total billed charges,,,12.85,,,percent of total billed charges,,,,,,,,,,,,,,,15.12,,,percent of total billed charges,,,8.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,15.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,
DEXAMETHASONE  SOD INJ 10 MG,2500001225,CDM,636,RC,J1100,HCPCS,6332350601,NDC,,,,outpatient,facility,1,ML,15.12,15.12,0.1,548.68,,10.72,,,percent of total billed charges,,,3.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,15.12,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,15.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.53,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.1,,,fee schedule,,,15.12,,,fee schedule,,,15.12,,,percent of total billed charges,,,,,,,,,15.12,,,percent of total billed charges,,,9.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,8.92,,,percent of total billed charges,,,548.68,,,per diem,,,15.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,15.12,,,percent of total billed charges,,,12.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.03,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.2,,,percent of total billed charges,,,12.24,,,percent of total billed charges,,,,,,,,,,,,,,,6.05,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15.12,,,percent of total billed charges,,,15.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.21,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,,,,,,,,,,,,,15.12,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.12,,,fee schedule,,,15.12,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,,,,,,,10.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.91,,,percent of total billed charges,,
DEXAMETHASONE  SOD INJ 10 MG,2500001225,CDM,636,RC,J1100,HCPCS,6332350601,NDC,496,EAPG,,outpatient,facility,1,ML,15.12,15.12,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAZOLAMIDE SOD INJ  500 MG,2500001240,CDM,636,RC,J1120,HCPCS,143950301,NDC,,,,inpatient,facility,500,UN,145.07,145.07,11.61,145.07,,,,,,,,,,,,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.07,,,percent of total billed charges,,,,,,,,,145.07,,,percent of total billed charges,,,74.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.04,,,percent of total billed charges,,,,,,,,,,,,,,,145.07,,,percent of total billed charges,,,123.31,,,percent of total billed charges,,,,,,,,,,,,,,,145.07,,,percent of total billed charges,,,77.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.48,,,percent of total billed charges,,
ACETAZOLAMIDE SOD INJ  500 MG,2500001240,CDM,636,RC,J1120,HCPCS,143950301,NDC,,,,outpatient,facility,500,UN,145.07,145.07,11.61,548.68,,102.87,,,percent of total billed charges,,,35.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,145.07,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,53.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,145.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,145.07,,,fee schedule,,,145.07,,,percent of total billed charges,,,,,,,,,145.07,,,percent of total billed charges,,,88.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,85.59,,,percent of total billed charges,,,548.68,,,per diem,,,145.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,145.07,,,percent of total billed charges,,,123.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.05,,,percent of total billed charges,,,145.07,,,percent of total billed charges,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.86,,,percent of total billed charges,,,117.39,,,percent of total billed charges,,,,,,,,,,,,,,,58.03,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,145.07,,,percent of total billed charges,,,145.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,145.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.61,,,percent of total billed charges,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,,145.07,,,percent of total billed charges,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,24.94,,,fee schedule,,,145.07,,,percent of total billed charges,,,145.07,,,percent of total billed charges,,,145.07,,,percent of total billed charges,,,,,,,,,101.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,85.48,,,percent of total billed charges,,
ACETAZOLAMIDE SOD INJ  500 MG,2500001240,CDM,636,RC,J1120,HCPCS,143950301,NDC,999,EAPG,,outpatient,facility,500,UN,145.07,145.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIGOXIN 0.5 MG/2 ML AMP,2500001250,CDM,636,RC,J1160,HCPCS,781305995,NDC,,,,inpatient,facility,2,UN,24.68,24.68,1.97,24.68,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,,,,,,,24.68,,,percent of total billed charges,,,12.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.81,,,percent of total billed charges,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,20.98,,,percent of total billed charges,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,13.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.54,,,percent of total billed charges,,
DIGOXIN 0.5 MG/2 ML AMP,2500001250,CDM,636,RC,J1160,HCPCS,781305995,NDC,,,,outpatient,facility,2,UN,24.68,24.68,1.38,548.68,,17.5,,,percent of total billed charges,,,6.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,24.68,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.03,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.38,,,fee schedule,,,24.68,,,fee schedule,,,24.68,,,percent of total billed charges,,,,,,,,,24.68,,,percent of total billed charges,,,15.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.58,,,percent of total billed charges,,,,,,,,,,,,,,,9.41,,,fee schedule,,,9.41,,,fee schedule,,,9.41,,,fee schedule,,,,,,,,,14.56,,,percent of total billed charges,,,548.68,,,per diem,,,24.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,24.68,,,percent of total billed charges,,,20.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.11,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.65,,,percent of total billed charges,,,19.97,,,percent of total billed charges,,,,,,,,,,,,,,,9.87,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,24.68,,,percent of total billed charges,,,24.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.97,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,24.68,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,7.45,,,fee schedule,,,24.68,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,,,,,,,17.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.54,,,percent of total billed charges,,
DIGOXIN 0.5 MG/2 ML AMP,2500001250,CDM,636,RC,J1160,HCPCS,781305995,NDC,496,EAPG,,outpatient,facility,2,UN,24.68,24.68,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYTOIN  SOD INJ 100 MG,2500001262,CDM,636,RC,J1165,HCPCS,641049325,NDC,,,,inpatient,facility,2,ML,4.59,4.59,0.37,4.59,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,,,,,,,4.59,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,3.9,,,percent of total billed charges,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,
PHENYTOIN  SOD INJ 100 MG,2500001262,CDM,636,RC,J1165,HCPCS,641049325,NDC,,,,outpatient,facility,2,ML,4.59,4.59,0.37,548.68,,3.25,,,percent of total billed charges,,,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.59,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.68,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.59,,,fee schedule,,,4.59,,,percent of total billed charges,,,,,,,,,4.59,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,2.71,,,percent of total billed charges,,,548.68,,,per diem,,,4.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.59,,,percent of total billed charges,,,3.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.44,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4.59,,,percent of total billed charges,,,4.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.37,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.52,,,fee schedule,,,4.59,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,,,,,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.7,,,percent of total billed charges,,
PHENYTOIN  SOD INJ 100 MG,2500001262,CDM,636,RC,J1165,HCPCS,641049325,NDC,999,EAPG,,outpatient,facility,2,ML,4.59,4.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYTOIN  SOD INJ 250 MG,2500001264,CDM,636,RC,J1165,HCPCS,641255545,NDC,,,,inpatient,facility,5,UN,6.56,6.56,0.52,6.56,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,6.56,,,percent of total billed charges,,,3.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.94,,,percent of total billed charges,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,5.58,,,percent of total billed charges,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,3.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,
PHENYTOIN  SOD INJ 250 MG,2500001264,CDM,636,RC,J1165,HCPCS,641255545,NDC,,,,outpatient,facility,5,UN,6.56,6.56,0.52,548.68,,4.65,,,percent of total billed charges,,,1.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.56,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.56,,,fee schedule,,,6.56,,,percent of total billed charges,,,,,,,,,6.56,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,3.87,,,percent of total billed charges,,,548.68,,,per diem,,,6.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.56,,,percent of total billed charges,,,5.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.48,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.43,,,percent of total billed charges,,,5.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6.56,,,percent of total billed charges,,,6.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.52,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.52,,,fee schedule,,,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.87,,,percent of total billed charges,,
PHENYTOIN  SOD INJ 250 MG,2500001264,CDM,636,RC,J1165,HCPCS,641255545,NDC,999,EAPG,,outpatient,facility,5,UN,6.56,6.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROMORPHONE INJ UP TO 20 MG,2500001274,CDM,636,RC,J1171,HCPCS,1747854050,NDC,,,,inpatient,facility,100,UN,841.5,841.5,67.32,841.5,,,,,,,,,,,,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,841.5,,,percent of total billed charges,,,,,,,,,841.5,,,percent of total billed charges,,,429.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,716.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,841.5,,,percent of total billed charges,,,715.28,,,percent of total billed charges,,,,,,,,,,,,,,,841.5,,,percent of total billed charges,,,446.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,336.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,495.81,,,percent of total billed charges,,
HYDROMORPHONE INJ UP TO 20 MG,2500001274,CDM,636,RC,J1171,HCPCS,1747854050,NDC,,,,outpatient,facility,100,UN,841.5,841.5,67.32,841.5,,596.71,,,percent of total billed charges,,,,,,,,,841.5,,,percent of total billed charges,,,527.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,591.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,591.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,841.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,841.5,,,fee schedule,,,841.5,,,percent of total billed charges,,,,,,,,,841.5,,,percent of total billed charges,,,515.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.57,,,percent of total billed charges,,,,,,,,,,,,,,,454.41,,,percent of total billed charges,,,437.58,,,percent of total billed charges,,,462.83,,,percent of total billed charges,,,,,,,,,496.48,,,percent of total billed charges,,,548.68,,,per diem,,,841.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,841.5,,,percent of total billed charges,,,715.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,446.92,,,percent of total billed charges,,,841.5,,,percent of total billed charges,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,567.68,,,percent of total billed charges,,,680.94,,,percent of total billed charges,,,,,,,,,,,,,,,336.6,,,percent of total billed charges,,,,,,,,,311.36,,,percent of total billed charges,,,311.36,,,percent of total billed charges,,,,,,,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,841.5,,,percent of total billed charges,,,841.5,,,percent of total billed charges,,,,,,,,,782.76,,,percent of total billed charges,,,,,,,,,,,,,,,782.76,,,percent of total billed charges,,,782.76,,,percent of total billed charges,,,782.76,,,percent of total billed charges,,,631.13,,,percent of total billed charges,,,841.5,,,percent of total billed charges,,,841.5,,,percent of total billed charges,,,841.5,,,percent of total billed charges,,,,,,,,,589.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,495.81,,,percent of total billed charges,,
HYDROMORPHONE INJ UP TO 20 MG,2500001274,CDM,636,RC,J1171,HCPCS,1747854050,NDC,791,APC,,outpatient,facility,100,UN,841.5,841.5,0.09,307.99,,,,,,,,0.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,307.99,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.1,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,
HYDROMORPHONE INJ UP TO 20 MG,2500001274,CDM,636,RC,J1171,HCPCS,1747854050,NDC,999,EAPG,,outpatient,facility,100,UN,841.5,841.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROMORPHONE 2 MG/ML INJ,2500001277,CDM,636,RC,J1171,HCPCS,641615125,NDC,,,,inpatient,facility,1,ML,9.9,9.9,0.79,9.9,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,5.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,5.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.83,,,percent of total billed charges,,
HYDROMORPHONE 2 MG/ML INJ,2500001277,CDM,636,RC,J1171,HCPCS,641615125,NDC,,,,outpatient,facility,1,ML,9.9,9.9,0.79,548.68,,7.02,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,6.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.9,,,fee schedule,,,9.9,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.05,,,percent of total billed charges,,,,,,,,,,,,,,,5.35,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,5.45,,,percent of total billed charges,,,,,,,,,5.84,,,percent of total billed charges,,,548.68,,,per diem,,,9.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.9,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.26,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.68,,,percent of total billed charges,,,8.01,,,percent of total billed charges,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,3.66,,,percent of total billed charges,,,3.66,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,6.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.83,,,percent of total billed charges,,
HYDROMORPHONE 2 MG/ML INJ,2500001277,CDM,636,RC,J1171,HCPCS,641615125,NDC,791,APC,,outpatient,facility,1,ML,9.9,9.9,0.09,3.62,,,,,,,,0.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,3.62,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.1,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,
HYDROMORPHONE 2 MG/ML INJ,2500001277,CDM,636,RC,J1171,HCPCS,641615125,NDC,999,EAPG,,outpatient,facility,1,ML,9.9,9.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROMORPHONE 1 MG INJ,2500001279,CDM,636,RC,J1171,HCPCS,6155316267,NDC,,,,inpatient,facility,5,UN,8.58,8.58,0.69,8.58,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,,,,,,,8.58,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,4.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.06,,,percent of total billed charges,,
HYDROMORPHONE 1 MG INJ,2500001279,CDM,636,RC,J1171,HCPCS,6155316267,NDC,,,,outpatient,facility,5,UN,8.58,8.58,0.69,548.68,,6.08,,,percent of total billed charges,,,,,,,,,8.58,,,percent of total billed charges,,,5.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.58,,,fee schedule,,,8.58,,,percent of total billed charges,,,,,,,,,8.58,,,percent of total billed charges,,,5.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.11,,,percent of total billed charges,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,5.06,,,percent of total billed charges,,,548.68,,,per diem,,,8.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.58,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.56,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.79,,,percent of total billed charges,,,6.94,,,percent of total billed charges,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,8.58,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,6.44,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.06,,,percent of total billed charges,,
HYDROMORPHONE 1 MG INJ,2500001279,CDM,636,RC,J1171,HCPCS,6155316267,NDC,791,APC,,outpatient,facility,5,UN,8.58,8.58,0.09,3.14,,,,,,,,0.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,3.14,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.1,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,
HYDROMORPHONE 1 MG INJ,2500001279,CDM,636,RC,J1171,HCPCS,6155316267,NDC,999,EAPG,,outpatient,facility,5,UN,8.58,8.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIPHENHYDRAMINE INJ 50 MG,2500001300,CDM,636,RC,J1200,HCPCS,,,,,,inpatient,facility,50,UN,9.93,9.93,0.79,9.93,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,,,,,,,9.93,,,percent of total billed charges,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.96,,,percent of total billed charges,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,8.44,,,percent of total billed charges,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,5.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.85,,,percent of total billed charges,,
DIPHENHYDRAMINE INJ 50 MG,2500001300,CDM,636,RC,J1200,HCPCS,,,,,,outpatient,facility,50,UN,9.93,9.93,0.79,548.68,,7.04,,,percent of total billed charges,,,2.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.93,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.89,,,fee schedule,,,9.93,,,fee schedule,,,9.93,,,percent of total billed charges,,,,,,,,,9.93,,,percent of total billed charges,,,6.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,5.86,,,percent of total billed charges,,,548.68,,,per diem,,,9.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.93,,,percent of total billed charges,,,8.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.27,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,8.04,,,percent of total billed charges,,,,,,,,,,,,,,,3.97,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9.93,,,percent of total billed charges,,,9.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.79,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.95,,,fee schedule,,,9.93,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.85,,,percent of total billed charges,,
DIPHENHYDRAMINE INJ 50 MG,2500001300,CDM,636,RC,J1200,HCPCS,496,EAPG,,,,outpatient,facility,50,UN,9.93,9.93,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLOROTHIAZIDE  INJ 500 MG,2500001310,CDM,636,RC,J1205,HCPCS,6332365820,NDC,,,,inpatient,facility,500,GR,982.41,982.41,78.59,982.41,,,,,,,,,,,,,,982.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,982.41,,,percent of total billed charges,,,,,,,,,982.41,,,percent of total billed charges,,,501.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,589.45,,,percent of total billed charges,,,,,,,,,,,,,,,982.41,,,percent of total billed charges,,,835.05,,,percent of total billed charges,,,,,,,,,,,,,,,982.41,,,percent of total billed charges,,,521.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,982.41,,,percent of total billed charges,,,,,,,,,,,,,,,78.59,,,percent of total billed charges,,,982.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,982.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.84,,,percent of total billed charges,,
CHLOROTHIAZIDE  INJ 500 MG,2500001310,CDM,636,RC,J1205,HCPCS,6332365820,NDC,,,,outpatient,facility,500,GR,982.41,982.41,66.2,982.41,,696.63,,,percent of total billed charges,,,239.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,982.41,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,982.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,359.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,982.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,982.41,,,fee schedule,,,982.41,,,percent of total billed charges,,,,,,,,,982.41,,,percent of total billed charges,,,602.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,699.97,,,percent of total billed charges,,,,,,,,,,,,,,,121.35,,,fee schedule,,,121.35,,,fee schedule,,,121.35,,,fee schedule,,,,,,,,,579.62,,,percent of total billed charges,,,548.68,,,per diem,,,982.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,982.41,,,percent of total billed charges,,,835.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,521.76,,,percent of total billed charges,,,982.41,,,percent of total billed charges,,,982.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,662.73,,,percent of total billed charges,,,794.97,,,percent of total billed charges,,,,,,,,,,,,,,,392.96,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,982.41,,,percent of total billed charges,,,982.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,982.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,78.59,,,percent of total billed charges,,,982.41,,,percent of total billed charges,,,,,,,,,,,,,,,982.41,,,percent of total billed charges,,,982.41,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,66.2,,,fee schedule,,,982.41,,,percent of total billed charges,,,982.41,,,percent of total billed charges,,,982.41,,,percent of total billed charges,,,,,,,,,688.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,491.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,578.84,,,percent of total billed charges,,
CHLOROTHIAZIDE  INJ 500 MG,2500001310,CDM,636,RC,J1205,HCPCS,6332365820,NDC,999,EAPG,,outpatient,facility,500,GR,982.41,982.41,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOBUTAMINE 500 MG IV,2500001365,CDM,636,RC,J1250,HCPCS,409234732,NDC,,,,inpatient,facility,250,UN,50.75,50.75,4.06,50.75,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,,,,,,,50.75,,,percent of total billed charges,,,25.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.45,,,percent of total billed charges,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,43.14,,,percent of total billed charges,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,26.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.9,,,percent of total billed charges,,
DOBUTAMINE 500 MG IV,2500001365,CDM,636,RC,J1250,HCPCS,409234732,NDC,,,,outpatient,facility,250,UN,50.75,50.75,4.06,548.68,,35.99,,,percent of total billed charges,,,12.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,50.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,18.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,50.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,50.75,,,fee schedule,,,50.75,,,percent of total billed charges,,,,,,,,,50.75,,,percent of total billed charges,,,31.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,29.94,,,percent of total billed charges,,,548.68,,,per diem,,,50.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,50.75,,,percent of total billed charges,,,43.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.95,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.24,,,percent of total billed charges,,,41.07,,,percent of total billed charges,,,,,,,,,,,,,,,20.3,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,50.75,,,percent of total billed charges,,,50.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,50.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.06,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,7.87,,,fee schedule,,,50.75,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,,,,,,,35.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,29.9,,,percent of total billed charges,,
DOBUTAMINE 500 MG IV,2500001365,CDM,636,RC,J1250,HCPCS,409234732,NDC,999,EAPG,,outpatient,facility,250,UN,50.75,50.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FIDAXOMICIN 200 MG TAB,2500001465,CDM,637,RC,5201508001,NDC,,,,,,inpatient,facility,200,UN,821.83,821.83,65.75,821.83,,,,,,,,,,,,,,821.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,821.83,,,percent of total billed charges,,,,,,,,,821.83,,,percent of total billed charges,,,419.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,699.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,493.1,,,percent of total billed charges,,,,,,,,,,,,,,,821.83,,,percent of total billed charges,,,698.56,,,percent of total billed charges,,,,,,,,,,,,,,,821.83,,,percent of total billed charges,,,436.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,821.83,,,percent of total billed charges,,,,,,,,,,,,,,,65.75,,,percent of total billed charges,,,821.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,821.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,484.22,,,percent of total billed charges,,
FIDAXOMICIN 200 MG TAB,2500001465,CDM,637,RC,5201508001,NDC,,,,,,outpatient,facility,200,UN,821.83,821.83,65.75,821.83,,582.76,,,percent of total billed charges,,,200.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,821.83,,,percent of total billed charges,,,515.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,577.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,577.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,821.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,300.79,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,821.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,821.83,,,fee schedule,,,821.83,,,percent of total billed charges,,,,,,,,,821.83,,,percent of total billed charges,,,503.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,585.55,,,percent of total billed charges,,,,,,,,,,,,,,,443.79,,,percent of total billed charges,,,427.35,,,percent of total billed charges,,,452.01,,,percent of total billed charges,,,,,,,,,484.88,,,percent of total billed charges,,,548.68,,,per diem,,,821.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,821.83,,,percent of total billed charges,,,698.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,436.47,,,percent of total billed charges,,,821.83,,,percent of total billed charges,,,821.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,554.41,,,percent of total billed charges,,,665.02,,,percent of total billed charges,,,,,,,,,,,,,,,328.73,,,percent of total billed charges,,,,,,,,,304.08,,,percent of total billed charges,,,304.08,,,percent of total billed charges,,,,,,,,,821.83,,,percent of total billed charges,,,821.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,821.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,65.75,,,percent of total billed charges,,,821.83,,,percent of total billed charges,,,,,,,,,,,,,,,821.83,,,percent of total billed charges,,,821.83,,,percent of total billed charges,,,,,,,,,764.47,,,percent of total billed charges,,,,,,,,,,,,,,,764.47,,,percent of total billed charges,,,764.47,,,percent of total billed charges,,,764.47,,,percent of total billed charges,,,616.37,,,percent of total billed charges,,,821.83,,,percent of total billed charges,,,821.83,,,percent of total billed charges,,,821.83,,,percent of total billed charges,,,,,,,,,576.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,484.22,,,percent of total billed charges,,
FIDAXOMICIN 200 MG TAB,2500001465,CDM,637,RC,5201508001,NDC,999,EAPG,,,,outpatient,facility,200,UN,821.83,821.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENTAMICIN IV PREMIX 120 MG,2500001651,CDM,636,RC,J1580,HCPCS,338050748,NDC,,,,inpatient,facility,100,UN,13.73,13.73,1.1,13.73,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,,,,,,,13.73,,,percent of total billed charges,,,7.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.24,,,percent of total billed charges,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,11.67,,,percent of total billed charges,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,
GENTAMICIN IV PREMIX 120 MG,2500001651,CDM,636,RC,J1580,HCPCS,338050748,NDC,,,,outpatient,facility,100,UN,13.73,13.73,1.08,548.68,,9.74,,,percent of total billed charges,,,3.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.73,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.03,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.08,,,fee schedule,,,13.73,,,fee schedule,,,13.73,,,percent of total billed charges,,,,,,,,,13.73,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,8.1,,,percent of total billed charges,,,548.68,,,per diem,,,13.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.73,,,percent of total billed charges,,,11.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.26,,,percent of total billed charges,,,11.11,,,percent of total billed charges,,,,,,,,,,,,,,,5.49,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13.73,,,percent of total billed charges,,,13.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.1,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.15,,,fee schedule,,,13.73,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,,,,,,,9.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.09,,,percent of total billed charges,,
GENTAMICIN IV PREMIX 120 MG,2500001651,CDM,636,RC,J1580,HCPCS,338050748,NDC,496,EAPG,,outpatient,facility,100,UN,13.73,13.73,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENTAMICIN 80 MG/2 ML INJ,2500001653,CDM,636,RC,J1580,HCPCS,6332301020,NDC,,,,inpatient,facility,100,UN,156.56,156.56,12.52,156.56,,,,,,,,,,,,,,156.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.56,,,percent of total billed charges,,,,,,,,,156.56,,,percent of total billed charges,,,79.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.94,,,percent of total billed charges,,,,,,,,,,,,,,,156.56,,,percent of total billed charges,,,133.08,,,percent of total billed charges,,,,,,,,,,,,,,,156.56,,,percent of total billed charges,,,83.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,156.56,,,percent of total billed charges,,,,,,,,,,,,,,,12.52,,,percent of total billed charges,,,156.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,156.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.25,,,percent of total billed charges,,
GENTAMICIN 80 MG/2 ML INJ,2500001653,CDM,636,RC,J1580,HCPCS,6332301020,NDC,,,,outpatient,facility,100,UN,156.56,156.56,1.08,548.68,,111.02,,,percent of total billed charges,,,38.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,156.56,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,156.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,57.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.08,,,fee schedule,,,156.56,,,fee schedule,,,156.56,,,percent of total billed charges,,,,,,,,,156.56,,,percent of total billed charges,,,95.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,92.37,,,percent of total billed charges,,,548.68,,,per diem,,,156.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,156.56,,,percent of total billed charges,,,133.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,83.15,,,percent of total billed charges,,,156.56,,,percent of total billed charges,,,156.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.62,,,percent of total billed charges,,,126.69,,,percent of total billed charges,,,,,,,,,,,,,,,62.62,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,156.56,,,percent of total billed charges,,,156.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,156.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.52,,,percent of total billed charges,,,156.56,,,percent of total billed charges,,,,,,,,,,,,,,,156.56,,,percent of total billed charges,,,156.56,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.15,,,fee schedule,,,156.56,,,percent of total billed charges,,,156.56,,,percent of total billed charges,,,156.56,,,percent of total billed charges,,,,,,,,,109.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,92.25,,,percent of total billed charges,,
GENTAMICIN 80 MG/2 ML INJ,2500001653,CDM,636,RC,J1580,HCPCS,6332301020,NDC,496,EAPG,,outpatient,facility,100,UN,156.56,156.56,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENTAMICIN 100MG/100ML NS PRMX,2500001656,CDM,636,RC,J1580,HCPCS,338050548,NDC,,,,inpatient,facility,100,UN,14.09,14.09,1.13,14.09,,,,,,,,,,,,,,14.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.09,,,percent of total billed charges,,,,,,,,,14.09,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,14.09,,,percent of total billed charges,,,11.98,,,percent of total billed charges,,,,,,,,,,,,,,,14.09,,,percent of total billed charges,,,7.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,14.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.3,,,percent of total billed charges,,
GENTAMICIN 100MG/100ML NS PRMX,2500001656,CDM,636,RC,J1580,HCPCS,338050548,NDC,,,,outpatient,facility,100,UN,14.09,14.09,1.08,548.68,,9.99,,,percent of total billed charges,,,3.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.09,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,14.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.16,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.08,,,fee schedule,,,14.09,,,fee schedule,,,14.09,,,percent of total billed charges,,,,,,,,,14.09,,,percent of total billed charges,,,8.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,8.31,,,percent of total billed charges,,,548.68,,,per diem,,,14.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.09,,,percent of total billed charges,,,11.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.48,,,percent of total billed charges,,,14.09,,,percent of total billed charges,,,14.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.51,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,14.09,,,percent of total billed charges,,,14.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.13,,,percent of total billed charges,,,14.09,,,percent of total billed charges,,,,,,,,,,,,,,,14.09,,,percent of total billed charges,,,14.09,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.15,,,fee schedule,,,14.09,,,percent of total billed charges,,,14.09,,,percent of total billed charges,,,14.09,,,percent of total billed charges,,,,,,,,,9.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.3,,,percent of total billed charges,,
GENTAMICIN 100MG/100ML NS PRMX,2500001656,CDM,636,RC,J1580,HCPCS,338050548,NDC,496,EAPG,,outpatient,facility,100,UN,14.09,14.09,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENTAMICIN 80MG/50ML NS PREMIX,2500001657,CDM,636,RC,J1580,HCPCS,338050941,NDC,,,,inpatient,facility,50,UN,13.43,13.43,1.07,13.43,,,,,,,,,,,,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.43,,,percent of total billed charges,,,,,,,,,13.43,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.06,,,percent of total billed charges,,,,,,,,,,,,,,,13.43,,,percent of total billed charges,,,11.42,,,percent of total billed charges,,,,,,,,,,,,,,,13.43,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.91,,,percent of total billed charges,,
GENTAMICIN 80MG/50ML NS PREMIX,2500001657,CDM,636,RC,J1580,HCPCS,338050941,NDC,,,,outpatient,facility,50,UN,13.43,13.43,1.07,548.68,,9.52,,,percent of total billed charges,,,3.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.43,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.92,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.08,,,fee schedule,,,13.43,,,fee schedule,,,13.43,,,percent of total billed charges,,,,,,,,,13.43,,,percent of total billed charges,,,8.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.92,,,percent of total billed charges,,,548.68,,,per diem,,,13.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.43,,,percent of total billed charges,,,11.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.06,,,percent of total billed charges,,,10.87,,,percent of total billed charges,,,,,,,,,,,,,,,5.37,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13.43,,,percent of total billed charges,,,13.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.07,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,13.43,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.15,,,fee schedule,,,13.43,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,,,,,,,9.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.91,,,percent of total billed charges,,
GENTAMICIN 80MG/50ML NS PREMIX,2500001657,CDM,636,RC,J1580,HCPCS,338050941,NDC,496,EAPG,,outpatient,facility,50,UN,13.43,13.43,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLUCAGON HCL INJ 1 MG,2500001670,CDM,636,RC,J1610,HCPCS,548585000,NDC,,,,inpatient,facility,1,UN,924,924,73.92,924,,,,,,,,,,,,,,924,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,924,,,percent of total billed charges,,,,,,,,,924,,,percent of total billed charges,,,471.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,786.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,554.4,,,percent of total billed charges,,,,,,,,,,,,,,,924,,,percent of total billed charges,,,785.4,,,percent of total billed charges,,,,,,,,,,,,,,,924,,,percent of total billed charges,,,490.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,369.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,924,,,percent of total billed charges,,,,,,,,,,,,,,,73.92,,,percent of total billed charges,,,924,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,924,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,544.42,,,percent of total billed charges,,
GLUCAGON HCL INJ 1 MG,2500001670,CDM,636,RC,J1610,HCPCS,548585000,NDC,,,,outpatient,facility,1,UN,924,924,73.92,924,,655.21,,,percent of total billed charges,,,,,,,,,924,,,percent of total billed charges,,,245.92,,,fee schedule,,,232.66,,,fee schedule,,,,,,,,,232.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,924,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,924,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,924,,,fee schedule,,,924,,,percent of total billed charges,,,,,,,,,924,,,percent of total billed charges,,,566.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,658.35,,,percent of total billed charges,,,,,,,,,,,,,,,188.37,,,fee schedule,,,188.37,,,fee schedule,,,188.37,,,fee schedule,,,,,,,,,545.16,,,percent of total billed charges,,,548.68,,,per diem,,,924,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,924,,,percent of total billed charges,,,785.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,490.74,,,percent of total billed charges,,,924,,,percent of total billed charges,,,924,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,623.33,,,percent of total billed charges,,,747.7,,,percent of total billed charges,,,,,,,,,,,,,,,369.6,,,percent of total billed charges,,,,,,,,,418.5,,,fee schedule,,,301.14,,,fee schedule,,,,,,,,,924,,,percent of total billed charges,,,,,,,,,,,,,,,73.92,,,percent of total billed charges,,,924,,,percent of total billed charges,,,,,,,,,,,,,,,924,,,percent of total billed charges,,,924,,,percent of total billed charges,,,,,,,,,178.85,,,fee schedule,,,,,,,,,,,,,,,155.01,,,fee schedule,,,206.68,,,fee schedule,,,116.25,,,fee schedule,,,196.61,,,fee schedule,,,924,,,percent of total billed charges,,,924,,,percent of total billed charges,,,924,,,percent of total billed charges,,,,,,,,,647.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,544.42,,,percent of total billed charges,,
GLUCAGON HCL INJ 1 MG,2500001670,CDM,636,RC,J1610,HCPCS,548585000,NDC,9042,APC,,outpatient,facility,1,UN,924,924,176.81,338.18,,,,,,,,189.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,184.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.02,,,fee schedule,,,,,,,,,338.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,184.18,,,fee schedule,,,,,,,,,,,,,,,193.39,,,fee schedule,,,193.39,,,fee schedule,,,,,,,,,184.18,,,fee schedule,,,184.18,,,fee schedule,,,193.39,,,fee schedule,,,,,,,,,,,,,,,276.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,184.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.81,,,fee schedule,,,197.07,,,fee schedule,,,193.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.18,,,fee schedule,,,184.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,191.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,184.18,,,fee schedule,,,,,,,,,230.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,230.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,184.18,,,fee schedule,,,184.18,,,fee schedule,,,,,,,,,,,,,,,184.18,,,fee schedule,,,,,,,,,184.18,,,fee schedule,,,189.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.18,,,fee schedule,,,,,,,,,,,,,,,191.55,,,fee schedule,,,184.18,,,fee schedule,,,,,,,,,184.18,,,fee schedule,,,,,,,,,184.18,,,fee schedule,,,193.39,,,fee schedule,,,,,,,,
GLUCAGON HCL INJ 1 MG,2500001670,CDM,636,RC,J1610,HCPCS,548585000,NDC,437,EAPG,,outpatient,facility,1,UN,924,924,156.28,235.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.98,,,fee schedule,,,156.28,,,fee schedule,,,209.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HALOPERIDOL LACT INJ 5 MG,2500001710,CDM,636,RC,J1630,HCPCS,6745742612,NDC,,,,inpatient,facility,1,ML,4.75,4.75,0.38,4.75,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,4.75,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,
HALOPERIDOL LACT INJ 5 MG,2500001710,CDM,636,RC,J1630,HCPCS,6745742612,NDC,,,,outpatient,facility,1,ML,4.75,4.75,0.38,548.68,,3.37,,,percent of total billed charges,,,1.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.96,,,fee schedule,,,4.75,,,fee schedule,,,4.75,,,percent of total billed charges,,,,,,,,,4.75,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,2.8,,,percent of total billed charges,,,548.68,,,per diem,,,4.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.75,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,3.84,,,percent of total billed charges,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4.75,,,percent of total billed charges,,,4.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.38,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.2,,,fee schedule,,,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.8,,,percent of total billed charges,,
HALOPERIDOL LACT INJ 5 MG,2500001710,CDM,636,RC,J1630,HCPCS,6745742612,NDC,496,EAPG,,outpatient,facility,1,ML,4.75,4.75,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HALOPERIDOL DEC INJ 50 MG,2500001720,CDM,636,RC,J1631,HCPCS,7006903003,NDC,,,,inpatient,facility,1,UN,103.12,103.12,8.25,103.12,,,,,,,,,,,,,,103.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.12,,,percent of total billed charges,,,,,,,,,103.12,,,percent of total billed charges,,,52.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.87,,,percent of total billed charges,,,,,,,,,,,,,,,103.12,,,percent of total billed charges,,,87.65,,,percent of total billed charges,,,,,,,,,,,,,,,103.12,,,percent of total billed charges,,,54.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,103.12,,,percent of total billed charges,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,103.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.76,,,percent of total billed charges,,
HALOPERIDOL DEC INJ 50 MG,2500001720,CDM,636,RC,J1631,HCPCS,7006903003,NDC,,,,outpatient,facility,1,UN,103.12,103.12,6.78,548.68,,73.12,,,percent of total billed charges,,,25.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,103.12,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,103.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,37.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,103.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,103.12,,,fee schedule,,,103.12,,,percent of total billed charges,,,,,,,,,103.12,,,percent of total billed charges,,,63.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,60.84,,,percent of total billed charges,,,548.68,,,per diem,,,103.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,103.12,,,percent of total billed charges,,,87.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.77,,,percent of total billed charges,,,103.12,,,percent of total billed charges,,,103.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.56,,,percent of total billed charges,,,83.44,,,percent of total billed charges,,,,,,,,,,,,,,,41.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,103.12,,,percent of total billed charges,,,103.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,103.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.25,,,percent of total billed charges,,,103.12,,,percent of total billed charges,,,,,,,,,,,,,,,103.12,,,percent of total billed charges,,,103.12,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,6.78,,,fee schedule,,,103.12,,,percent of total billed charges,,,103.12,,,percent of total billed charges,,,103.12,,,percent of total billed charges,,,,,,,,,72.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,60.76,,,percent of total billed charges,,
HALOPERIDOL DEC INJ 50 MG,2500001720,CDM,636,RC,J1631,HCPCS,7006903003,NDC,435,EAPG,,outpatient,facility,1,UN,103.12,103.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEPARIN LOCK FLUSH 100 U ML 5M,2500001725,CDM,636,RC,J1642,HCPCS,6425333335,NDC,,,,inpatient,facility,5,UN,12.24,12.24,0.98,12.24,,,,,,,,,,,,,,12.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.24,,,percent of total billed charges,,,,,,,,,12.24,,,percent of total billed charges,,,6.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.34,,,percent of total billed charges,,,,,,,,,,,,,,,12.24,,,percent of total billed charges,,,10.4,,,percent of total billed charges,,,,,,,,,,,,,,,12.24,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,12.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.21,,,percent of total billed charges,,
HEPARIN LOCK FLUSH 100 U ML 5M,2500001725,CDM,636,RC,J1642,HCPCS,6425333335,NDC,,,,outpatient,facility,5,UN,12.24,12.24,0.02,548.68,,8.68,,,percent of total billed charges,,,2.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,12.24,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,12.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.48,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,12.24,,,fee schedule,,,12.24,,,percent of total billed charges,,,,,,,,,12.24,,,percent of total billed charges,,,7.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.22,,,percent of total billed charges,,,548.68,,,per diem,,,12.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12.24,,,percent of total billed charges,,,10.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,12.24,,,percent of total billed charges,,,12.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.26,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,4.9,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12.24,,,percent of total billed charges,,,12.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.98,,,percent of total billed charges,,,12.24,,,percent of total billed charges,,,,,,,,,,,,,,,12.24,,,percent of total billed charges,,,12.24,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.02,,,fee schedule,,,12.24,,,percent of total billed charges,,,12.24,,,percent of total billed charges,,,12.24,,,percent of total billed charges,,,,,,,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.21,,,percent of total billed charges,,
HEPARIN LOCK FLUSH 100 U ML 5M,2500001725,CDM,636,RC,J1642,HCPCS,6425333335,NDC,496,EAPG,,outpatient,facility,5,UN,12.24,12.24,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEPARIN LOCK FLUSH 30 UNIT 3 M,2500001727,CDM,636,RC,J1642,HCPCS,6425322223,NDC,,,,inpatient,facility,3,UN,9.86,9.86,0.79,9.86,,,,,,,,,,,,,,9.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.86,,,percent of total billed charges,,,,,,,,,9.86,,,percent of total billed charges,,,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.92,,,percent of total billed charges,,,,,,,,,,,,,,,9.86,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,9.86,,,percent of total billed charges,,,5.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.86,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,9.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,
HEPARIN LOCK FLUSH 30 UNIT 3 M,2500001727,CDM,636,RC,J1642,HCPCS,6425322223,NDC,,,,outpatient,facility,3,UN,9.86,9.86,0.02,548.68,,6.99,,,percent of total billed charges,,,2.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.86,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.86,,,fee schedule,,,9.86,,,percent of total billed charges,,,,,,,,,9.86,,,percent of total billed charges,,,6.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,5.82,,,percent of total billed charges,,,548.68,,,per diem,,,9.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.86,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.24,,,percent of total billed charges,,,9.86,,,percent of total billed charges,,,9.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.65,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,3.94,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9.86,,,percent of total billed charges,,,9.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.79,,,percent of total billed charges,,,9.86,,,percent of total billed charges,,,,,,,,,,,,,,,9.86,,,percent of total billed charges,,,9.86,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.02,,,fee schedule,,,9.86,,,percent of total billed charges,,,9.86,,,percent of total billed charges,,,9.86,,,percent of total billed charges,,,,,,,,,6.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.81,,,percent of total billed charges,,
HEPARIN LOCK FLUSH 30 UNIT 3 M,2500001727,CDM,636,RC,J1642,HCPCS,6425322223,NDC,496,EAPG,,outpatient,facility,3,UN,9.86,9.86,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEPARIN  SOD INJ 5000 U/ML 1ML,2500001732,CDM,636,RC,J1644,HCPCS,2502140201,NDC,,,,inpatient,facility,1,UN,4.95,4.95,0.4,4.95,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,4.95,,,percent of total billed charges,,,2.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,2.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,
HEPARIN  SOD INJ 5000 U/ML 1ML,2500001732,CDM,636,RC,J1644,HCPCS,2502140201,NDC,,,,outpatient,facility,1,UN,4.95,4.95,0.24,548.68,,3.51,,,percent of total billed charges,,,1.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.81,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.95,,,fee schedule,,,4.95,,,percent of total billed charges,,,,,,,,,4.95,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,2.92,,,percent of total billed charges,,,548.68,,,per diem,,,4.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.95,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.63,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.34,,,percent of total billed charges,,,4.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4.95,,,percent of total billed charges,,,4.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.4,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.24,,,fee schedule,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.92,,,percent of total billed charges,,
HEPARIN  SOD INJ 5000 U/ML 1ML,2500001732,CDM,636,RC,J1644,HCPCS,2502140201,NDC,496,EAPG,,outpatient,facility,1,UN,4.95,4.95,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEPARIN  SOD INJ 10000U/10ML,2500001734,CDM,636,RC,J1644,HCPCS,6332354015,NDC,,,,inpatient,facility,10,UN,23.99,23.99,1.92,23.99,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,,,,,,,23.99,,,percent of total billed charges,,,12.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.39,,,percent of total billed charges,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,20.39,,,percent of total billed charges,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.13,,,percent of total billed charges,,
HEPARIN  SOD INJ 10000U/10ML,2500001734,CDM,636,RC,J1644,HCPCS,6332354015,NDC,,,,outpatient,facility,10,UN,23.99,23.99,0.24,548.68,,17.01,,,percent of total billed charges,,,5.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,23.99,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.78,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,23.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,23.99,,,fee schedule,,,23.99,,,percent of total billed charges,,,,,,,,,23.99,,,percent of total billed charges,,,14.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,14.15,,,percent of total billed charges,,,548.68,,,per diem,,,23.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,23.99,,,percent of total billed charges,,,20.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.18,,,percent of total billed charges,,,19.41,,,percent of total billed charges,,,,,,,,,,,,,,,9.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,23.99,,,percent of total billed charges,,,23.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.92,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.24,,,fee schedule,,,23.99,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,,,,,,,16.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.13,,,percent of total billed charges,,
HEPARIN  SOD INJ 10000U/10ML,2500001734,CDM,636,RC,J1644,HCPCS,6332354015,NDC,496,EAPG,,outpatient,facility,10,UN,23.99,23.99,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEPARIN 1000 U/500 ML NS,2500001735,CDM,636,RC,J1644,HCPCS,409100520,NDC,,,,inpatient,facility,500,ML,18.15,18.15,1.45,18.15,,,,,,,,,,,,,,18.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.15,,,percent of total billed charges,,,,,,,,,18.15,,,percent of total billed charges,,,9.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.89,,,percent of total billed charges,,,,,,,,,,,,,,,18.15,,,percent of total billed charges,,,15.43,,,percent of total billed charges,,,,,,,,,,,,,,,18.15,,,percent of total billed charges,,,9.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,18.15,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,18.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.69,,,percent of total billed charges,,
HEPARIN 1000 U/500 ML NS,2500001735,CDM,636,RC,J1644,HCPCS,409100520,NDC,,,,outpatient,facility,500,ML,18.15,18.15,0.24,548.68,,12.87,,,percent of total billed charges,,,4.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,18.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,18.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.64,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,18.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,18.15,,,fee schedule,,,18.15,,,percent of total billed charges,,,,,,,,,18.15,,,percent of total billed charges,,,11.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,10.71,,,percent of total billed charges,,,548.68,,,per diem,,,18.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,18.15,,,percent of total billed charges,,,15.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.64,,,percent of total billed charges,,,18.15,,,percent of total billed charges,,,18.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.24,,,percent of total billed charges,,,14.69,,,percent of total billed charges,,,,,,,,,,,,,,,7.26,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,18.15,,,percent of total billed charges,,,18.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.45,,,percent of total billed charges,,,18.15,,,percent of total billed charges,,,,,,,,,,,,,,,18.15,,,percent of total billed charges,,,18.15,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.24,,,fee schedule,,,18.15,,,percent of total billed charges,,,18.15,,,percent of total billed charges,,,18.15,,,percent of total billed charges,,,,,,,,,12.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.69,,,percent of total billed charges,,
HEPARIN 1000 U/500 ML NS,2500001735,CDM,636,RC,J1644,HCPCS,409100520,NDC,496,EAPG,,outpatient,facility,500,ML,18.15,18.15,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEPARIN 2000 U/1000ML IV SOLN,2500001737,CDM,636,RC,J1644,HCPCS,409222212,NDC,,,,inpatient,facility,1000,UN,25.64,25.64,2.05,25.64,,,,,,,,,,,,,,25.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.64,,,percent of total billed charges,,,,,,,,,25.64,,,percent of total billed charges,,,13.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.38,,,percent of total billed charges,,,,,,,,,,,,,,,25.64,,,percent of total billed charges,,,21.79,,,percent of total billed charges,,,,,,,,,,,,,,,25.64,,,percent of total billed charges,,,13.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,25.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,25.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.11,,,percent of total billed charges,,
HEPARIN 2000 U/1000ML IV SOLN,2500001737,CDM,636,RC,J1644,HCPCS,409222212,NDC,,,,outpatient,facility,1000,UN,25.64,25.64,0.24,548.68,,18.18,,,percent of total billed charges,,,6.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,25.64,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,25.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.38,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,25.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,25.64,,,fee schedule,,,25.64,,,percent of total billed charges,,,,,,,,,25.64,,,percent of total billed charges,,,15.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,15.13,,,percent of total billed charges,,,548.68,,,per diem,,,25.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,25.64,,,percent of total billed charges,,,21.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.62,,,percent of total billed charges,,,25.64,,,percent of total billed charges,,,25.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.3,,,percent of total billed charges,,,20.75,,,percent of total billed charges,,,,,,,,,,,,,,,10.26,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,25.64,,,percent of total billed charges,,,25.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.05,,,percent of total billed charges,,,25.64,,,percent of total billed charges,,,,,,,,,,,,,,,25.64,,,percent of total billed charges,,,25.64,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.24,,,fee schedule,,,25.64,,,percent of total billed charges,,,25.64,,,percent of total billed charges,,,25.64,,,percent of total billed charges,,,,,,,,,17.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15.11,,,percent of total billed charges,,
HEPARIN 2000 U/1000ML IV SOLN,2500001737,CDM,636,RC,J1644,HCPCS,409222212,NDC,496,EAPG,,outpatient,facility,1000,UN,25.64,25.64,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEPARIN  SOD INJ 25000 U,2500001739,CDM,636,RC,J1644,HCPCS,264958720,NDC,,,,inpatient,facility,250,UN,50.72,50.72,4.06,50.72,,,,,,,,,,,,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.72,,,percent of total billed charges,,,,,,,,,50.72,,,percent of total billed charges,,,25.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.43,,,percent of total billed charges,,,,,,,,,,,,,,,50.72,,,percent of total billed charges,,,43.11,,,percent of total billed charges,,,,,,,,,,,,,,,50.72,,,percent of total billed charges,,,26.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.88,,,percent of total billed charges,,
HEPARIN  SOD INJ 25000 U,2500001739,CDM,636,RC,J1644,HCPCS,264958720,NDC,,,,outpatient,facility,250,UN,50.72,50.72,0.24,548.68,,35.97,,,percent of total billed charges,,,12.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,50.72,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,18.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,50.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,50.72,,,fee schedule,,,50.72,,,percent of total billed charges,,,,,,,,,50.72,,,percent of total billed charges,,,31.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,29.92,,,percent of total billed charges,,,548.68,,,per diem,,,50.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,50.72,,,percent of total billed charges,,,43.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.94,,,percent of total billed charges,,,50.72,,,percent of total billed charges,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.22,,,percent of total billed charges,,,41.04,,,percent of total billed charges,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,50.72,,,percent of total billed charges,,,50.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,50.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.06,,,percent of total billed charges,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,,50.72,,,percent of total billed charges,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.24,,,fee schedule,,,50.72,,,percent of total billed charges,,,50.72,,,percent of total billed charges,,,50.72,,,percent of total billed charges,,,,,,,,,35.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,29.88,,,percent of total billed charges,,
HEPARIN  SOD INJ 25000 U,2500001739,CDM,636,RC,J1644,HCPCS,264958720,NDC,496,EAPG,,outpatient,facility,250,UN,50.72,50.72,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEPARIN  SOD INJ 1000 U 1 ML,2500001740,CDM,636,RC,J1644,HCPCS,409272001,NDC,,,,inpatient,facility,1,UN,6.13,6.13,0.49,6.13,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,,,,,,,6.13,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.61,,,percent of total billed charges,,
HEPARIN  SOD INJ 1000 U 1 ML,2500001740,CDM,636,RC,J1644,HCPCS,409272001,NDC,,,,outpatient,facility,1,UN,6.13,6.13,0.24,548.68,,4.35,,,percent of total billed charges,,,1.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.13,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.24,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.13,,,fee schedule,,,6.13,,,percent of total billed charges,,,,,,,,,6.13,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,3.62,,,percent of total billed charges,,,548.68,,,per diem,,,6.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.13,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.14,,,percent of total billed charges,,,4.96,,,percent of total billed charges,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6.13,,,percent of total billed charges,,,6.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.49,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.24,,,fee schedule,,,6.13,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,,,,,,,4.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.61,,,percent of total billed charges,,
HEPARIN  SOD INJ 1000 U 1 ML,2500001740,CDM,636,RC,J1644,HCPCS,409272001,NDC,496,EAPG,,outpatient,facility,1,UN,6.13,6.13,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEPARIN LK FL 10 U/ML 5 ML SYR,2500001741,CDM,636,RC,J1642,HCPCS,6380750055,NDC,,,,inpatient,facility,5,UN,11.55,11.55,0.92,11.55,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,11.55,,,percent of total billed charges,,,5.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,9.82,,,percent of total billed charges,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.81,,,percent of total billed charges,,
HEPARIN LK FL 10 U/ML 5 ML SYR,2500001741,CDM,636,RC,J1642,HCPCS,6380750055,NDC,,,,outpatient,facility,5,UN,11.55,11.55,0.02,548.68,,8.19,,,percent of total billed charges,,,2.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,11.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,11.55,,,fee schedule,,,11.55,,,percent of total billed charges,,,,,,,,,11.55,,,percent of total billed charges,,,7.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,6.81,,,percent of total billed charges,,,548.68,,,per diem,,,11.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11.55,,,percent of total billed charges,,,9.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,9.35,,,percent of total billed charges,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11.55,,,percent of total billed charges,,,11.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.92,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.02,,,fee schedule,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,8.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.81,,,percent of total billed charges,,
HEPARIN LK FL 10 U/ML 5 ML SYR,2500001741,CDM,636,RC,J1642,HCPCS,6380750055,NDC,496,EAPG,,outpatient,facility,5,UN,11.55,11.55,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENOXAPARIN SOD INJ 150 MG,2500001759,CDM,636,RC,J1650,HCPCS,6050507984,NDC,,,,inpatient,facility,1,ML,89.1,89.1,7.13,89.1,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,,,,,,,89.1,,,percent of total billed charges,,,45.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,75.74,,,percent of total billed charges,,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.5,,,percent of total billed charges,,
ENOXAPARIN SOD INJ 150 MG,2500001759,CDM,636,RC,J1650,HCPCS,6050507984,NDC,,,,outpatient,facility,1,ML,89.1,89.1,0.59,548.68,,63.18,,,percent of total billed charges,,,21.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,89.1,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,32.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.22,,,fee schedule,,,89.1,,,fee schedule,,,89.1,,,percent of total billed charges,,,,,,,,,89.1,,,percent of total billed charges,,,54.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,52.57,,,percent of total billed charges,,,548.68,,,per diem,,,89.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,89.1,,,percent of total billed charges,,,75.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.32,,,percent of total billed charges,,,89.1,,,percent of total billed charges,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.11,,,percent of total billed charges,,,72.1,,,percent of total billed charges,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,89.1,,,percent of total billed charges,,,89.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,89.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.13,,,percent of total billed charges,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,89.1,,,percent of total billed charges,,,89.1,,,percent of total billed charges,,,89.1,,,percent of total billed charges,,,,,,,,,62.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,52.5,,,percent of total billed charges,,
ENOXAPARIN SOD INJ 150 MG,2500001759,CDM,636,RC,J1650,HCPCS,6050507984,NDC,496,EAPG,,outpatient,facility,1,ML,89.1,89.1,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENOXAPARIN  SOD INJ 30 MG,2500001760,CDM,636,RC,J1650,HCPCS,548560100,NDC,,,,inpatient,facility,0.3,ML,14.85,14.85,1.19,14.85,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,,,,,,,14.85,,,percent of total billed charges,,,7.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,12.62,,,percent of total billed charges,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.75,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 30 MG,2500001760,CDM,636,RC,J1650,HCPCS,548560100,NDC,,,,outpatient,facility,0.3,ML,14.85,14.85,0.59,548.68,,10.53,,,percent of total billed charges,,,3.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.22,,,fee schedule,,,14.85,,,fee schedule,,,14.85,,,percent of total billed charges,,,,,,,,,14.85,,,percent of total billed charges,,,9.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,8.76,,,percent of total billed charges,,,548.68,,,per diem,,,14.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.85,,,percent of total billed charges,,,12.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.02,,,percent of total billed charges,,,12.02,,,percent of total billed charges,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,14.85,,,percent of total billed charges,,,14.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.19,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,14.85,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,,,,,,,10.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.75,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 30 MG,2500001760,CDM,636,RC,J1650,HCPCS,548560100,NDC,496,EAPG,,outpatient,facility,0.3,ML,14.85,14.85,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENOXAPARIN  SOD INJ 40 MG,2500001762,CDM,636,RC,J1650,HCPCS,7128843383,NDC,,,,inpatient,facility,0.4,ML,12.14,12.14,0.97,12.14,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,12.14,,,percent of total billed charges,,,6.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.28,,,percent of total billed charges,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,6.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,0.97,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.15,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 40 MG,2500001762,CDM,636,RC,J1650,HCPCS,7128843383,NDC,,,,outpatient,facility,0.4,ML,12.14,12.14,0.59,548.68,,8.61,,,percent of total billed charges,,,2.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,12.14,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.22,,,fee schedule,,,12.14,,,fee schedule,,,12.14,,,percent of total billed charges,,,,,,,,,12.14,,,percent of total billed charges,,,7.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.16,,,percent of total billed charges,,,548.68,,,per diem,,,12.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12.14,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.45,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.19,,,percent of total billed charges,,,9.82,,,percent of total billed charges,,,,,,,,,,,,,,,4.86,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12.14,,,percent of total billed charges,,,12.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.97,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,12.14,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,,,,,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.15,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 40 MG,2500001762,CDM,636,RC,J1650,HCPCS,7128843383,NDC,496,EAPG,,outpatient,facility,0.4,ML,12.14,12.14,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENOXAPARIN  SOD INJ 120 MG,2500001763,CDM,636,RC,J1650,HCPCS,7128841181,NDC,,,,inpatient,facility,0.8,ML,59.4,59.4,4.75,59.4,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,30.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,31.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 120 MG,2500001763,CDM,636,RC,J1650,HCPCS,7128841181,NDC,,,,outpatient,facility,0.8,ML,59.4,59.4,0.59,548.68,,42.12,,,percent of total billed charges,,,14.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,59.4,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,21.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.22,,,fee schedule,,,59.4,,,fee schedule,,,59.4,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,36.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,35.05,,,percent of total billed charges,,,548.68,,,per diem,,,59.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,59.4,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.55,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.07,,,percent of total billed charges,,,48.07,,,percent of total billed charges,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,59.4,,,percent of total billed charges,,,59.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,59.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.75,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,41.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,35,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 120 MG,2500001763,CDM,636,RC,J1650,HCPCS,7128841181,NDC,496,EAPG,,outpatient,facility,0.8,ML,59.4,59.4,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENOXAPARIN  SOD INJ 100 MG,2500001764,CDM,636,RC,J1650,HCPCS,6050507954,NDC,,,,inpatient,facility,1,ML,59.4,59.4,4.75,59.4,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,30.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,31.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 100 MG,2500001764,CDM,636,RC,J1650,HCPCS,6050507954,NDC,,,,outpatient,facility,1,ML,59.4,59.4,0.59,548.68,,42.12,,,percent of total billed charges,,,14.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,59.4,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,21.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.22,,,fee schedule,,,59.4,,,fee schedule,,,59.4,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,36.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,35.05,,,percent of total billed charges,,,548.68,,,per diem,,,59.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,59.4,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.55,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.07,,,percent of total billed charges,,,48.07,,,percent of total billed charges,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,59.4,,,percent of total billed charges,,,59.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,59.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.75,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,,,,,,,41.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,35,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 100 MG,2500001764,CDM,636,RC,J1650,HCPCS,6050507954,NDC,496,EAPG,,outpatient,facility,1,ML,59.4,59.4,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENOXAPARIN  SOD INJ 60 MG,2500001766,CDM,636,RC,J1650,HCPCS,6050507934,NDC,,,,inpatient,facility,0.6,ML,35.64,35.64,2.85,35.64,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,35.64,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.38,,,percent of total billed charges,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,30.29,,,percent of total billed charges,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,18.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 60 MG,2500001766,CDM,636,RC,J1650,HCPCS,6050507934,NDC,,,,outpatient,facility,0.6,ML,35.64,35.64,0.59,548.68,,25.27,,,percent of total billed charges,,,8.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,35.64,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,13.04,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.22,,,fee schedule,,,35.64,,,fee schedule,,,35.64,,,percent of total billed charges,,,,,,,,,35.64,,,percent of total billed charges,,,21.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,21.03,,,percent of total billed charges,,,548.68,,,per diem,,,35.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,35.64,,,percent of total billed charges,,,30.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.93,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.04,,,percent of total billed charges,,,28.84,,,percent of total billed charges,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,35.64,,,percent of total billed charges,,,35.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.85,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,24.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,21,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 60 MG,2500001766,CDM,636,RC,J1650,HCPCS,6050507934,NDC,496,EAPG,,outpatient,facility,0.6,ML,35.64,35.64,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENOXAPARIN  SOD INJ 80 MG,2500001768,CDM,636,RC,J1650,HCPCS,6050507944,NDC,,,,inpatient,facility,0.8,ML,47.52,47.52,3.8,47.52,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,,,,,,,47.52,,,percent of total billed charges,,,24.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,40.39,,,percent of total billed charges,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,25.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 80 MG,2500001768,CDM,636,RC,J1650,HCPCS,6050507944,NDC,,,,outpatient,facility,0.8,ML,47.52,47.52,0.59,548.68,,33.7,,,percent of total billed charges,,,11.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,47.52,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,17.39,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.22,,,fee schedule,,,47.52,,,fee schedule,,,47.52,,,percent of total billed charges,,,,,,,,,47.52,,,percent of total billed charges,,,29.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,28.04,,,percent of total billed charges,,,548.68,,,per diem,,,47.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,47.52,,,percent of total billed charges,,,40.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.24,,,percent of total billed charges,,,47.52,,,percent of total billed charges,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.06,,,percent of total billed charges,,,38.45,,,percent of total billed charges,,,,,,,,,,,,,,,19.01,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,47.52,,,percent of total billed charges,,,47.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,47.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.8,,,percent of total billed charges,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,47.52,,,percent of total billed charges,,,47.52,,,percent of total billed charges,,,47.52,,,percent of total billed charges,,,,,,,,,33.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,28,,,percent of total billed charges,,
ENOXAPARIN  SOD INJ 80 MG,2500001768,CDM,636,RC,J1650,HCPCS,6050507944,NDC,496,EAPG,,outpatient,facility,0.8,ML,47.52,47.52,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCORT SOD SUCC INJ 100 MG,2500001810,CDM,636,RC,J1720,HCPCS,9001104,NDC,,,,inpatient,facility,2,UN,70.72,70.72,5.66,70.72,,,,,,,,,,,,,,70.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.72,,,percent of total billed charges,,,,,,,,,70.72,,,percent of total billed charges,,,36.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.43,,,percent of total billed charges,,,,,,,,,,,,,,,70.72,,,percent of total billed charges,,,60.11,,,percent of total billed charges,,,,,,,,,,,,,,,70.72,,,percent of total billed charges,,,37.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,70.72,,,percent of total billed charges,,,,,,,,,,,,,,,5.66,,,percent of total billed charges,,,70.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.67,,,percent of total billed charges,,
HYDROCORT SOD SUCC INJ 100 MG,2500001810,CDM,636,RC,J1720,HCPCS,9001104,NDC,,,,outpatient,facility,2,UN,70.72,70.72,4.42,548.68,,50.15,,,percent of total billed charges,,,17.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,70.72,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,70.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,25.88,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.42,,,fee schedule,,,70.72,,,fee schedule,,,70.72,,,percent of total billed charges,,,,,,,,,70.72,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,41.72,,,percent of total billed charges,,,548.68,,,per diem,,,70.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,70.72,,,percent of total billed charges,,,60.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.56,,,percent of total billed charges,,,70.72,,,percent of total billed charges,,,70.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.71,,,percent of total billed charges,,,57.23,,,percent of total billed charges,,,,,,,,,,,,,,,28.29,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,70.72,,,percent of total billed charges,,,70.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,70.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.66,,,percent of total billed charges,,,70.72,,,percent of total billed charges,,,,,,,,,,,,,,,70.72,,,percent of total billed charges,,,70.72,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,20.6,,,fee schedule,,,70.72,,,percent of total billed charges,,,70.72,,,percent of total billed charges,,,70.72,,,percent of total billed charges,,,,,,,,,49.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,41.67,,,percent of total billed charges,,
HYDROCORT SOD SUCC INJ 100 MG,2500001810,CDM,636,RC,J1720,HCPCS,9001104,NDC,496,EAPG,,outpatient,facility,2,UN,70.72,70.72,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOROLAC INJ 30MG,2500001980,CDM,636,RC,J1885,HCPCS,7226611825,NDC,,,,inpatient,facility,1,ML,5.77,5.77,0.46,5.77,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,5.77,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,4.9,,,percent of total billed charges,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,3.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,
KETOROLAC INJ 30MG,2500001980,CDM,636,RC,J1885,HCPCS,7226611825,NDC,,,,outpatient,facility,1,ML,5.77,5.77,0.32,548.68,,4.09,,,percent of total billed charges,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.32,,,fee schedule,,,5.77,,,fee schedule,,,5.77,,,percent of total billed charges,,,,,,,,,5.77,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,3.4,,,percent of total billed charges,,,548.68,,,per diem,,,5.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.77,,,percent of total billed charges,,,4.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,4.67,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.87,,,fee schedule,,,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,4.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.4,,,percent of total billed charges,,
KETOROLAC INJ 30MG,2500001980,CDM,636,RC,J1885,HCPCS,7226611825,NDC,764,APC,,outpatient,facility,1,ML,5.77,5.77,0.75,5.77,,,,,,,,1.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOROLAC INJ 30MG,2500001980,CDM,636,RC,J1885,HCPCS,7226611825,NDC,496,EAPG,,outpatient,facility,1,ML,5.77,5.77,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOROLAC INJ 60 MG,2500001982,CDM,636,RC,J1885,HCPCS,7261172525,NDC,,,,inpatient,facility,2,ML,4.92,4.92,0.39,4.92,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,,,,,,,4.92,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,4.18,,,percent of total billed charges,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,
KETOROLAC INJ 60 MG,2500001982,CDM,636,RC,J1885,HCPCS,7261172525,NDC,,,,outpatient,facility,2,ML,4.92,4.92,0.32,548.68,,3.49,,,percent of total billed charges,,,,,,,,,4.92,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.32,,,fee schedule,,,4.92,,,fee schedule,,,4.92,,,percent of total billed charges,,,,,,,,,4.92,,,percent of total billed charges,,,3.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,2.9,,,percent of total billed charges,,,548.68,,,per diem,,,4.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.92,,,percent of total billed charges,,,4.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.32,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.87,,,fee schedule,,,4.92,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,,,,,,,3.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.9,,,percent of total billed charges,,
KETOROLAC INJ 60 MG,2500001982,CDM,636,RC,J1885,HCPCS,7261172525,NDC,764,APC,,outpatient,facility,2,ML,4.92,4.92,0.75,4.92,,,,,,,,1.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOROLAC INJ 60 MG,2500001982,CDM,636,RC,J1885,HCPCS,7261172525,NDC,496,EAPG,,outpatient,facility,2,ML,4.92,4.92,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FUROSEMIDE INJ 40 MG,2500002020,CDM,636,RC,J1940,HCPCS,3600028325,NDC,,,,inpatient,facility,4,ML,3.92,3.92,0.31,3.92,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,,,,3.92,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,
FUROSEMIDE INJ 40 MG,2500002020,CDM,636,RC,J1940,HCPCS,3600028325,NDC,,,,outpatient,facility,4,ML,3.92,3.92,0.31,548.68,,2.78,,,percent of total billed charges,,,0.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.92,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.43,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.92,,,fee schedule,,,3.92,,,percent of total billed charges,,,,,,,,,3.92,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,2.31,,,percent of total billed charges,,,548.68,,,per diem,,,3.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.92,,,percent of total billed charges,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3.92,,,percent of total billed charges,,,3.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.31,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.45,,,fee schedule,,,3.92,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.31,,,percent of total billed charges,,
FUROSEMIDE INJ 40 MG,2500002020,CDM,636,RC,J1940,HCPCS,3600028325,NDC,999,EAPG,,outpatient,facility,4,ML,3.92,3.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FUROSEMIDE INJ 100 MG,2500002022,CDM,636,RC,J1940,HCPCS,3600028425,NDC,,,,inpatient,facility,10,ML,5.87,5.87,0.47,5.87,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,,,,,,,5.87,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,4.99,,,percent of total billed charges,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,3.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,
FUROSEMIDE INJ 100 MG,2500002022,CDM,636,RC,J1940,HCPCS,3600028425,NDC,,,,outpatient,facility,10,ML,5.87,5.87,0.45,548.68,,4.16,,,percent of total billed charges,,,1.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.87,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.15,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.87,,,fee schedule,,,5.87,,,percent of total billed charges,,,,,,,,,5.87,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,3.46,,,percent of total billed charges,,,548.68,,,per diem,,,5.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.87,,,percent of total billed charges,,,4.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,5.87,,,percent of total billed charges,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5.87,,,percent of total billed charges,,,5.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.47,,,percent of total billed charges,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.45,,,fee schedule,,,5.87,,,percent of total billed charges,,,5.87,,,percent of total billed charges,,,5.87,,,percent of total billed charges,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.46,,,percent of total billed charges,,
FUROSEMIDE INJ 100 MG,2500002022,CDM,636,RC,J1940,HCPCS,3600028425,NDC,999,EAPG,,outpatient,facility,10,ML,5.87,5.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FUROSEMIDE INJ 20MG,2500002024,CDM,636,RC,J1940,HCPCS,3600028225,NDC,,,,inpatient,facility,2,ML,3.56,3.56,0.28,3.56,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,3.56,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.1,,,percent of total billed charges,,
FUROSEMIDE INJ 20MG,2500002024,CDM,636,RC,J1940,HCPCS,3600028225,NDC,,,,outpatient,facility,2,ML,3.56,3.56,0.28,548.68,,2.52,,,percent of total billed charges,,,0.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.56,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.56,,,fee schedule,,,3.56,,,percent of total billed charges,,,,,,,,,3.56,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,2.1,,,percent of total billed charges,,,548.68,,,per diem,,,3.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.56,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,2.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3.56,,,percent of total billed charges,,,3.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.45,,,fee schedule,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.1,,,percent of total billed charges,,
FUROSEMIDE INJ 20MG,2500002024,CDM,636,RC,J1940,HCPCS,3600028225,NDC,999,EAPG,,outpatient,facility,2,ML,3.56,3.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEUPROLIDE ACET DEPOT 3.75 MG,2500002030,CDM,636,RC,J1950,HCPCS,74364103,NDC,,,,inpatient,facility,3.75,UN,5660.62,5660.62,452.85,5660.62,,,,,,,,,,,,,,5660.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5660.62,,,percent of total billed charges,,,,,,,,,5660.62,,,percent of total billed charges,,,2890.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4821.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3396.37,,,percent of total billed charges,,,,,,,,,,,,,,,5660.62,,,percent of total billed charges,,,4811.53,,,percent of total billed charges,,,,,,,,,,,,,,,5660.62,,,percent of total billed charges,,,3006.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2264.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5660.62,,,percent of total billed charges,,,,,,,,,,,,,,,452.85,,,percent of total billed charges,,,5660.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5660.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3335.24,,,percent of total billed charges,,
LEUPROLIDE ACET DEPOT 3.75 MG,2500002030,CDM,636,RC,J1950,HCPCS,74364103,NDC,,,,outpatient,facility,3.75,UN,5660.62,5660.62,357.82,5660.62,,4013.95,,,percent of total billed charges,,,,,,,,,5660.62,,,percent of total billed charges,,,2172.76,,,fee schedule,,,2055.59,,,fee schedule,,,,,,,,,2055.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,5660.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,682.91,,,fee schedule,,,5660.62,,,fee schedule,,,5660.62,,,percent of total billed charges,,,,,,,,,5660.62,,,percent of total billed charges,,,3469.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4033.19,,,percent of total billed charges,,,,,,,,,,,,,,,1564.6,,,fee schedule,,,1564.6,,,fee schedule,,,1564.6,,,fee schedule,,,,,,,,,3339.77,,,percent of total billed charges,,,548.68,,,per diem,,,5660.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5660.62,,,percent of total billed charges,,,4811.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3006.36,,,percent of total billed charges,,,5660.62,,,percent of total billed charges,,,5660.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3818.65,,,percent of total billed charges,,,4580.57,,,percent of total billed charges,,,,,,,,,,,,,,,2264.25,,,percent of total billed charges,,,,,,,,,3630.34,,,fee schedule,,,2612.31,,,fee schedule,,,,,,,,,5660.62,,,percent of total billed charges,,,,,,,,,,,,,,,452.85,,,percent of total billed charges,,,5660.62,,,percent of total billed charges,,,,,,,,,,,,,,,5660.62,,,percent of total billed charges,,,5660.62,,,percent of total billed charges,,,,,,,,,1551.43,,,fee schedule,,,,,,,,,,,,,,,1344.65,,,fee schedule,,,1792.86,,,fee schedule,,,1008.43,,,fee schedule,,,1737.1,,,fee schedule,,,5660.62,,,percent of total billed charges,,,5660.62,,,percent of total billed charges,,,5660.62,,,percent of total billed charges,,,,,,,,,3968.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2830.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3335.24,,,percent of total billed charges,,
LEUPROLIDE ACET DEPOT 3.75 MG,2500002030,CDM,636,RC,J1950,HCPCS,74364103,NDC,800,APC,,outpatient,facility,3.75,UN,5660.62,5660.62,1600.11,2500.17,,,,,,,,1716.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1666.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1683.45,,,fee schedule,,,,,,,,,2071.79,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,1666.78,,,fee schedule,,,,,,,,,,,,,,,1750.12,,,fee schedule,,,1750.12,,,fee schedule,,,,,,,,,1666.78,,,fee schedule,,,1666.78,,,fee schedule,,,1750.12,,,fee schedule,,,,,,,,,,,,,,,2500.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1666.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1600.11,,,fee schedule,,,1783.45,,,fee schedule,,,1750.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.78,,,fee schedule,,,1666.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1733.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.78,,,fee schedule,,,,,,,,,2083.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2083.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,1666.78,,,fee schedule,,,1666.78,,,fee schedule,,,,,,,,,,,,,,,1666.78,,,fee schedule,,,,,,,,,1666.78,,,fee schedule,,,1716.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.78,,,fee schedule,,,,,,,,,,,,,,,1733.45,,,fee schedule,,,1666.78,,,fee schedule,,,,,,,,,1666.78,,,fee schedule,,,,,,,,,1666.78,,,fee schedule,,,1750.12,,,fee schedule,,,,,,,,
LEUPROLIDE ACET DEPOT 3.75 MG,2500002030,CDM,636,RC,J1950,HCPCS,74364103,NDC,444,EAPG,,outpatient,facility,3.75,UN,5660.62,5660.62,1304.36,1969.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1969.58,,,fee schedule,,,1304.36,,,fee schedule,,,1750.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEUPROLIDE ACET DEPOT 11.25 MG,2500002033,CDM,636,RC,J1950,HCPCS,74228203,NDC,,,,inpatient,facility,11.25,UN,12362.99,12362.99,989.04,12362.99,,,,,,,,,,,,,,12362.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12362.99,,,percent of total billed charges,,,,,,,,,12362.99,,,percent of total billed charges,,,6312.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10529.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7417.79,,,percent of total billed charges,,,,,,,,,,,,,,,12362.99,,,percent of total billed charges,,,10508.54,,,percent of total billed charges,,,,,,,,,,,,,,,12362.99,,,percent of total billed charges,,,6565.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4945.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12362.99,,,percent of total billed charges,,,,,,,,,,,,,,,989.04,,,percent of total billed charges,,,12362.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12362.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7284.27,,,percent of total billed charges,,
LEUPROLIDE ACET DEPOT 11.25 MG,2500002033,CDM,636,RC,J1950,HCPCS,74228203,NDC,,,,outpatient,facility,11.25,UN,12362.99,12362.99,357.82,12362.99,,8766.6,,,percent of total billed charges,,,,,,,,,12362.99,,,percent of total billed charges,,,2172.76,,,fee schedule,,,2055.59,,,fee schedule,,,,,,,,,2055.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,12362.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,682.91,,,fee schedule,,,12362.99,,,fee schedule,,,12362.99,,,percent of total billed charges,,,,,,,,,12362.99,,,percent of total billed charges,,,7577.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8808.63,,,percent of total billed charges,,,,,,,,,,,,,,,1564.6,,,fee schedule,,,1564.6,,,fee schedule,,,1564.6,,,fee schedule,,,,,,,,,7294.16,,,percent of total billed charges,,,548.68,,,per diem,,,12362.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12362.99,,,percent of total billed charges,,,10508.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6565.98,,,percent of total billed charges,,,12362.99,,,percent of total billed charges,,,12362.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8340.07,,,percent of total billed charges,,,10004.13,,,percent of total billed charges,,,,,,,,,,,,,,,4945.2,,,percent of total billed charges,,,,,,,,,3630.34,,,fee schedule,,,2612.31,,,fee schedule,,,,,,,,,12362.99,,,percent of total billed charges,,,,,,,,,,,,,,,989.04,,,percent of total billed charges,,,12362.99,,,percent of total billed charges,,,,,,,,,,,,,,,12362.99,,,percent of total billed charges,,,12362.99,,,percent of total billed charges,,,,,,,,,1551.43,,,fee schedule,,,,,,,,,,,,,,,1344.65,,,fee schedule,,,1792.86,,,fee schedule,,,1008.43,,,fee schedule,,,1737.1,,,fee schedule,,,12362.99,,,percent of total billed charges,,,12362.99,,,percent of total billed charges,,,12362.99,,,percent of total billed charges,,,,,,,,,8667.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6181.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7284.27,,,percent of total billed charges,,
LEUPROLIDE ACET DEPOT 11.25 MG,2500002033,CDM,636,RC,J1950,HCPCS,74228203,NDC,800,APC,,outpatient,facility,11.25,UN,12362.99,12362.99,1600.11,4524.85,,,,,,,,1716.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1666.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1683.45,,,fee schedule,,,,,,,,,4524.85,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,1666.78,,,fee schedule,,,,,,,,,,,,,,,1750.12,,,fee schedule,,,1750.12,,,fee schedule,,,,,,,,,1666.78,,,fee schedule,,,1666.78,,,fee schedule,,,1750.12,,,fee schedule,,,,,,,,,,,,,,,2500.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1666.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1600.11,,,fee schedule,,,1783.45,,,fee schedule,,,1750.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.78,,,fee schedule,,,1666.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1733.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.78,,,fee schedule,,,,,,,,,2083.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2083.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,1666.78,,,fee schedule,,,1666.78,,,fee schedule,,,,,,,,,,,,,,,1666.78,,,fee schedule,,,,,,,,,1666.78,,,fee schedule,,,1716.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.78,,,fee schedule,,,,,,,,,,,,,,,1733.45,,,fee schedule,,,1666.78,,,fee schedule,,,,,,,,,1666.78,,,fee schedule,,,,,,,,,1666.78,,,fee schedule,,,1750.12,,,fee schedule,,,,,,,,
LEUPROLIDE ACET DEPOT 11.25 MG,2500002033,CDM,636,RC,J1950,HCPCS,74228203,NDC,444,EAPG,,outpatient,facility,11.25,UN,12362.99,12362.99,1304.36,1969.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1969.58,,,fee schedule,,,1304.36,,,fee schedule,,,1750.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 1  30 ML INJ,2500002092,CDM,250,RC,J2003,HCPCS,6332349207,NDC,,,,inpatient,facility,30,UN,33.83,33.83,2.71,33.83,,,,,,,,,,,,,,33.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.83,,,percent of total billed charges,,,,,,,,,33.83,,,percent of total billed charges,,,17.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.3,,,percent of total billed charges,,,,,,,,,,,,,,,33.83,,,percent of total billed charges,,,28.76,,,percent of total billed charges,,,,,,,,,,,,,,,33.83,,,percent of total billed charges,,,17.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,33.83,,,percent of total billed charges,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,33.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.93,,,percent of total billed charges,,
LIDOCAINE HCL 1  30 ML INJ,2500002092,CDM,250,RC,J2003,HCPCS,6332349207,NDC,,,,outpatient,facility,30,UN,33.83,33.83,2.71,548.68,,23.99,,,percent of total billed charges,,,8.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,33.83,,,percent of total billed charges,,,21.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,23.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,23.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,33.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.38,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,33.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,33.83,,,fee schedule,,,33.83,,,percent of total billed charges,,,,,,,,,33.83,,,percent of total billed charges,,,20.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,19.96,,,percent of total billed charges,,,548.68,,,per diem,,,33.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,33.83,,,percent of total billed charges,,,28.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.97,,,percent of total billed charges,,,33.83,,,percent of total billed charges,,,33.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.82,,,percent of total billed charges,,,27.38,,,percent of total billed charges,,,,,,,,,,,,,,,13.53,,,percent of total billed charges,,,,,,,,,12.52,,,percent of total billed charges,,,12.52,,,percent of total billed charges,,,,,,,,,33.83,,,percent of total billed charges,,,33.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.71,,,percent of total billed charges,,,33.83,,,percent of total billed charges,,,,,,,,,,,,,,,33.83,,,percent of total billed charges,,,33.83,,,percent of total billed charges,,,,,,,,,31.47,,,percent of total billed charges,,,,,,,,,,,,,,,31.47,,,percent of total billed charges,,,31.47,,,percent of total billed charges,,,31.47,,,percent of total billed charges,,,25.37,,,percent of total billed charges,,,33.83,,,percent of total billed charges,,,33.83,,,percent of total billed charges,,,33.83,,,percent of total billed charges,,,,,,,,,23.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,19.93,,,percent of total billed charges,,
LIDOCAINE HCL 1  30 ML INJ,2500002092,CDM,250,RC,J2003,HCPCS,6332349207,NDC,999,EAPG,,outpatient,facility,30,UN,33.83,33.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 1  5 ML AMP,2500002093,CDM,636,RC,J2003,HCPCS,5515015974,NDC,,,,inpatient,facility,5,UN,8.81,8.81,0.7,8.81,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,8.81,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.29,,,percent of total billed charges,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.19,,,percent of total billed charges,,
LIDOCAINE HCL 1  5 ML AMP,2500002093,CDM,636,RC,J2003,HCPCS,5515015974,NDC,,,,outpatient,facility,5,UN,8.81,8.81,0.7,548.68,,6.25,,,percent of total billed charges,,,2.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.81,,,percent of total billed charges,,,5.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.81,,,fee schedule,,,8.81,,,percent of total billed charges,,,,,,,,,8.81,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.28,,,percent of total billed charges,,,,,,,,,,,,,,,4.76,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,4.85,,,percent of total billed charges,,,,,,,,,5.2,,,percent of total billed charges,,,548.68,,,per diem,,,8.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.81,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,,,,,,,,3.26,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,,,,,,,8.81,,,percent of total billed charges,,,8.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.7,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,8.2,,,percent of total billed charges,,,,,,,,,,,,,,,8.2,,,percent of total billed charges,,,8.2,,,percent of total billed charges,,,8.2,,,percent of total billed charges,,,6.61,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,6.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.19,,,percent of total billed charges,,
LIDOCAINE HCL 1  5 ML AMP,2500002093,CDM,636,RC,J2003,HCPCS,5515015974,NDC,999,EAPG,,outpatient,facility,5,UN,8.81,8.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 2  50 ML INJ,2500002097,CDM,250,RC,J2003,HCPCS,143957510,NDC,,,,inpatient,facility,50,UN,12.14,12.14,0.97,12.14,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,12.14,,,percent of total billed charges,,,6.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.28,,,percent of total billed charges,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,6.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,0.97,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.15,,,percent of total billed charges,,
LIDOCAINE HCL 2  50 ML INJ,2500002097,CDM,250,RC,J2003,HCPCS,143957510,NDC,,,,outpatient,facility,50,UN,12.14,12.14,0.97,548.68,,8.61,,,percent of total billed charges,,,2.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,12.14,,,percent of total billed charges,,,7.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,12.14,,,fee schedule,,,12.14,,,percent of total billed charges,,,,,,,,,12.14,,,percent of total billed charges,,,7.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.16,,,percent of total billed charges,,,548.68,,,per diem,,,12.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12.14,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.45,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.19,,,percent of total billed charges,,,9.82,,,percent of total billed charges,,,,,,,,,,,,,,,4.86,,,percent of total billed charges,,,,,,,,,4.49,,,percent of total billed charges,,,4.49,,,percent of total billed charges,,,,,,,,,12.14,,,percent of total billed charges,,,12.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.97,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,,,,,,,11.29,,,percent of total billed charges,,,,,,,,,,,,,,,11.29,,,percent of total billed charges,,,11.29,,,percent of total billed charges,,,11.29,,,percent of total billed charges,,,9.11,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,,,,,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.15,,,percent of total billed charges,,
LIDOCAINE HCL 2  50 ML INJ,2500002097,CDM,250,RC,J2003,HCPCS,143957510,NDC,999,EAPG,,outpatient,facility,50,UN,12.14,12.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 3.5  OPHTH GEL 1 ML,2500002099,CDM,637,RC,1747879201,NDC,,,,,,inpatient,facility,1,UN,96.36,96.36,7.71,96.36,,,,,,,,,,,,,,96.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.36,,,percent of total billed charges,,,,,,,,,96.36,,,percent of total billed charges,,,49.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.82,,,percent of total billed charges,,,,,,,,,,,,,,,96.36,,,percent of total billed charges,,,81.91,,,percent of total billed charges,,,,,,,,,,,,,,,96.36,,,percent of total billed charges,,,51.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,96.36,,,percent of total billed charges,,,,,,,,,,,,,,,7.71,,,percent of total billed charges,,,96.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,96.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.78,,,percent of total billed charges,,
LIDOCAINE 3.5  OPHTH GEL 1 ML,2500002099,CDM,637,RC,1747879201,NDC,,,,,,outpatient,facility,1,UN,96.36,96.36,7.71,548.68,,68.33,,,percent of total billed charges,,,23.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,96.36,,,percent of total billed charges,,,60.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,67.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,67.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,96.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,35.27,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,96.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,96.36,,,fee schedule,,,96.36,,,percent of total billed charges,,,,,,,,,96.36,,,percent of total billed charges,,,59.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.66,,,percent of total billed charges,,,,,,,,,,,,,,,52.03,,,percent of total billed charges,,,50.11,,,percent of total billed charges,,,53,,,percent of total billed charges,,,,,,,,,56.85,,,percent of total billed charges,,,548.68,,,per diem,,,96.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,96.36,,,percent of total billed charges,,,81.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.18,,,percent of total billed charges,,,96.36,,,percent of total billed charges,,,96.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65,,,percent of total billed charges,,,77.97,,,percent of total billed charges,,,,,,,,,,,,,,,38.54,,,percent of total billed charges,,,,,,,,,35.65,,,percent of total billed charges,,,35.65,,,percent of total billed charges,,,,,,,,,96.36,,,percent of total billed charges,,,96.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,96.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.71,,,percent of total billed charges,,,96.36,,,percent of total billed charges,,,,,,,,,,,,,,,96.36,,,percent of total billed charges,,,96.36,,,percent of total billed charges,,,,,,,,,89.63,,,percent of total billed charges,,,,,,,,,,,,,,,89.63,,,percent of total billed charges,,,89.63,,,percent of total billed charges,,,89.63,,,percent of total billed charges,,,72.27,,,percent of total billed charges,,,96.36,,,percent of total billed charges,,,96.36,,,percent of total billed charges,,,96.36,,,percent of total billed charges,,,,,,,,,67.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,56.78,,,percent of total billed charges,,
LIDOCAINE 3.5  OPHTH GEL 1 ML,2500002099,CDM,637,RC,1747879201,NDC,999,EAPG,,,,outpatient,facility,1,UN,96.36,96.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LORAZEPAM INJ 2 MG,2500002110,CDM,636,RC,J2060,HCPCS,641604425,NDC,,,,inpatient,facility,1,ML,4.26,4.26,0.34,4.26,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,,,,,,,4.26,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,3.62,,,percent of total billed charges,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,
LORAZEPAM INJ 2 MG,2500002110,CDM,636,RC,J2060,HCPCS,641604425,NDC,,,,outpatient,facility,1,ML,4.26,4.26,0.34,548.68,,3.02,,,percent of total billed charges,,,1.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.26,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.82,,,fee schedule,,,4.26,,,fee schedule,,,4.26,,,percent of total billed charges,,,,,,,,,4.26,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,2.51,,,percent of total billed charges,,,548.68,,,per diem,,,4.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.26,,,percent of total billed charges,,,3.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,3.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4.26,,,percent of total billed charges,,,4.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.34,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.35,,,fee schedule,,,4.26,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,,,,,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.51,,,percent of total billed charges,,
LORAZEPAM INJ 2 MG,2500002110,CDM,636,RC,J2060,HCPCS,641604425,NDC,496,EAPG,,outpatient,facility,1,ML,4.26,4.26,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MANNITOL INJ 25   50 ML,2500002120,CDM,636,RC,J2150,HCPCS,409403101,NDC,,,,inpatient,facility,50,UN,9.7,9.7,0.78,9.7,,,,,,,,,,,,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.7,,,percent of total billed charges,,,,,,,,,9.7,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.82,,,percent of total billed charges,,,,,,,,,,,,,,,9.7,,,percent of total billed charges,,,8.24,,,percent of total billed charges,,,,,,,,,,,,,,,9.7,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.72,,,percent of total billed charges,,
MANNITOL INJ 25   50 ML,2500002120,CDM,636,RC,J2150,HCPCS,409403101,NDC,,,,outpatient,facility,50,UN,9.7,9.7,0.78,548.68,,6.88,,,percent of total billed charges,,,2.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.55,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.07,,,fee schedule,,,9.7,,,fee schedule,,,9.7,,,percent of total billed charges,,,,,,,,,9.7,,,percent of total billed charges,,,5.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,5.72,,,percent of total billed charges,,,548.68,,,per diem,,,9.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.7,,,percent of total billed charges,,,8.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,9.7,,,percent of total billed charges,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.54,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,3.88,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9.7,,,percent of total billed charges,,,9.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.78,,,percent of total billed charges,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,9.7,,,percent of total billed charges,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3,,,fee schedule,,,9.7,,,percent of total billed charges,,,9.7,,,percent of total billed charges,,,9.7,,,percent of total billed charges,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.72,,,percent of total billed charges,,
MANNITOL INJ 25   50 ML,2500002120,CDM,636,RC,J2150,HCPCS,409403101,NDC,496,EAPG,,outpatient,facility,50,UN,9.7,9.7,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEPERIDINE INJ 50 MG,2500002137,CDM,636,RC,J2175,HCPCS,641605301,NDC,,,,inpatient,facility,1,UN,13.2,13.2,1.06,13.2,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,6.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,11.22,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,7.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.78,,,percent of total billed charges,,
MEPERIDINE INJ 50 MG,2500002137,CDM,636,RC,J2175,HCPCS,641605301,NDC,,,,outpatient,facility,1,UN,13.2,13.2,1.06,548.68,,9.36,,,percent of total billed charges,,,3.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.83,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.14,,,fee schedule,,,13.2,,,fee schedule,,,13.2,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.79,,,percent of total billed charges,,,548.68,,,per diem,,,13.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.2,,,percent of total billed charges,,,11.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.01,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.9,,,percent of total billed charges,,,10.68,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13.2,,,percent of total billed charges,,,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,6.25,,,fee schedule,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,9.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.78,,,percent of total billed charges,,
MEPERIDINE INJ 50 MG,2500002137,CDM,636,RC,J2175,HCPCS,641605301,NDC,496,EAPG,,outpatient,facility,1,UN,13.2,13.2,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEUPROLIDE ACET 45 MG,2500002148,CDM,636,RC,J9217,HCPCS,6293545345,NDC,,,,inpatient,facility,45,UN,8943.43,8943.43,715.47,8943.43,,,,,,,,,,,,,,8943.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8943.43,,,percent of total billed charges,,,,,,,,,8943.43,,,percent of total billed charges,,,4566.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7617.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5366.06,,,percent of total billed charges,,,,,,,,,,,,,,,8943.43,,,percent of total billed charges,,,7601.92,,,percent of total billed charges,,,,,,,,,,,,,,,8943.43,,,percent of total billed charges,,,4749.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3577.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8943.43,,,percent of total billed charges,,,,,,,,,,,,,,,715.47,,,percent of total billed charges,,,8943.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8943.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5269.47,,,percent of total billed charges,,
LEUPROLIDE ACET 45 MG,2500002148,CDM,636,RC,J9217,HCPCS,6293545345,NDC,,,,outpatient,facility,45,UN,8943.43,8943.43,113.61,8943.43,,185.66,,,fee schedule,,,,,,,,,8943.43,,,percent of total billed charges,,,234.34,,,fee schedule,,,221.7,,,fee schedule,,,,,,,,,221.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,8943.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,230.11,,,fee schedule,,,8943.43,,,fee schedule,,,8943.43,,,percent of total billed charges,,,,,,,,,8943.43,,,percent of total billed charges,,,5481.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6372.19,,,percent of total billed charges,,,,,,,,,,,,,,,181.3,,,fee schedule,,,181.3,,,fee schedule,,,181.3,,,fee schedule,,,,,,,,,5276.62,,,percent of total billed charges,,,548.68,,,per diem,,,8943.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8943.43,,,percent of total billed charges,,,7601.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4749.86,,,percent of total billed charges,,,8943.43,,,percent of total billed charges,,,8943.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6033.24,,,percent of total billed charges,,,7237.02,,,percent of total billed charges,,,,,,,,,,,,,,,3577.37,,,percent of total billed charges,,,,,,,,,409.02,,,fee schedule,,,294.32,,,fee schedule,,,,,,,,,8943.43,,,percent of total billed charges,,,,,,,,,,,,,,,715.47,,,percent of total billed charges,,,8943.43,,,percent of total billed charges,,,,,,,,,,,,,,,8943.43,,,percent of total billed charges,,,8943.43,,,percent of total billed charges,,,,,,,,,174.79,,,fee schedule,,,,,,,,,,,,,,,151.49,,,fee schedule,,,201.99,,,fee schedule,,,113.61,,,fee schedule,,,187.35,,,fee schedule,,,8943.43,,,percent of total billed charges,,,8943.43,,,percent of total billed charges,,,8943.43,,,percent of total billed charges,,,,,,,,,6270.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4471.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5269.47,,,percent of total billed charges,,
LEUPROLIDE ACET 45 MG,2500002148,CDM,636,RC,J9217,HCPCS,6293545345,NDC,9217,APC,,outpatient,facility,45,UN,8943.43,8943.43,173.56,3273.3,,,,,,,,186.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.6,,,fee schedule,,,,,,,,,3273.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,189.83,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,180.79,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,,,,,,,,271.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.56,,,fee schedule,,,193.45,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,180.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,188.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,225.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,225.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,180.79,,,fee schedule,,,180.79,,,fee schedule,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,186.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,188.02,,,fee schedule,,,180.79,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,
LEUPROLIDE ACET 45 MG,2500002148,CDM,636,RC,J9217,HCPCS,6293545345,NDC,434,EAPG,,outpatient,facility,45,UN,8943.43,8943.43,380.24,574.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,574.16,,,fee schedule,,,380.24,,,fee schedule,,,510.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,380.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,380.24,,,fee schedule,,,380.24,,,fee schedule,,,380.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,380.24,,,fee schedule,,,,,,,,,,,,,,,380.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLERGONOVIN MAL INJ 0.2 MG,2500002150,CDM,636,RC,J2210,HCPCS,5199114417,NDC,,,,inpatient,facility,1,UN,78.24,78.24,6.26,78.24,,,,,,,,,,,,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.24,,,percent of total billed charges,,,,,,,,,78.24,,,percent of total billed charges,,,39.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.94,,,percent of total billed charges,,,,,,,,,,,,,,,78.24,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,78.24,,,percent of total billed charges,,,41.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.1,,,percent of total billed charges,,
METHYLERGONOVIN MAL INJ 0.2 MG,2500002150,CDM,636,RC,J2210,HCPCS,5199114417,NDC,,,,outpatient,facility,1,UN,78.24,78.24,6.26,548.68,,55.48,,,percent of total billed charges,,,19.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,78.24,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,28.64,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,78.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,78.24,,,fee schedule,,,78.24,,,percent of total billed charges,,,,,,,,,78.24,,,percent of total billed charges,,,47.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,46.16,,,percent of total billed charges,,,548.68,,,per diem,,,78.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,78.24,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.55,,,percent of total billed charges,,,78.24,,,percent of total billed charges,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.78,,,percent of total billed charges,,,63.31,,,percent of total billed charges,,,,,,,,,,,,,,,31.3,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,78.24,,,percent of total billed charges,,,78.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,78.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.26,,,percent of total billed charges,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,,78.24,,,percent of total billed charges,,,78.24,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,21.58,,,fee schedule,,,78.24,,,percent of total billed charges,,,78.24,,,percent of total billed charges,,,78.24,,,percent of total billed charges,,,,,,,,,54.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,46.1,,,percent of total billed charges,,
METHYLERGONOVIN MAL INJ 0.2 MG,2500002150,CDM,636,RC,J2210,HCPCS,5199114417,NDC,999,EAPG,,outpatient,facility,1,UN,78.24,78.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MIDAZOLAM HCL 1MG/ML  2 ML IN,2500002171,CDM,636,RC,J2250,HCPCS,409230517,NDC,,,,inpatient,facility,2,UN,2.14,2.14,0.17,2.14,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,2.14,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,
MIDAZOLAM HCL 1MG/ML  2 ML IN,2500002171,CDM,636,RC,J2250,HCPCS,409230517,NDC,,,,outpatient,facility,2,UN,2.14,2.14,0.08,548.68,,1.52,,,percent of total billed charges,,,0.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.14,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.78,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.08,,,fee schedule,,,2.14,,,fee schedule,,,2.14,,,percent of total billed charges,,,,,,,,,2.14,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,1.26,,,percent of total billed charges,,,548.68,,,per diem,,,2.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.14,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2.14,,,percent of total billed charges,,,2.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.14,,,fee schedule,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.26,,,percent of total billed charges,,
MIDAZOLAM HCL 1MG/ML  2 ML IN,2500002171,CDM,636,RC,J2250,HCPCS,409230517,NDC,496,EAPG,,outpatient,facility,2,UN,2.14,2.14,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MIDAZOLAM HCL INJ  5 MG,2500002172,CDM,636,RC,J2250,HCPCS,409230801,NDC,,,,inpatient,facility,1,UN,3.83,3.83,0.31,3.83,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,3.83,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,
MIDAZOLAM HCL INJ  5 MG,2500002172,CDM,636,RC,J2250,HCPCS,409230801,NDC,,,,outpatient,facility,1,UN,3.83,3.83,0.08,548.68,,2.72,,,percent of total billed charges,,,0.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.83,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.08,,,fee schedule,,,3.83,,,fee schedule,,,3.83,,,percent of total billed charges,,,,,,,,,3.83,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,2.26,,,percent of total billed charges,,,548.68,,,per diem,,,3.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.83,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3.83,,,percent of total billed charges,,,3.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.31,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.14,,,fee schedule,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,,,,,,,2.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.26,,,percent of total billed charges,,
MIDAZOLAM HCL INJ  5 MG,2500002172,CDM,636,RC,J2250,HCPCS,409230801,NDC,496,EAPG,,outpatient,facility,1,UN,3.83,3.83,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MIDAZOLAM HCL INJ  50MG,2500002176,CDM,636,RC,J2250,HCPCS,7261174910,NDC,,,,inpatient,facility,10,ML,23.36,23.36,1.87,23.36,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,,,,23.36,,,percent of total billed charges,,,11.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,12.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,
MIDAZOLAM HCL INJ  50MG,2500002176,CDM,636,RC,J2250,HCPCS,7261174910,NDC,,,,outpatient,facility,10,ML,23.36,23.36,0.08,548.68,,16.56,,,percent of total billed charges,,,5.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,23.36,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.55,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.08,,,fee schedule,,,23.36,,,fee schedule,,,23.36,,,percent of total billed charges,,,,,,,,,23.36,,,percent of total billed charges,,,14.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,13.78,,,percent of total billed charges,,,548.68,,,per diem,,,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,23.36,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.41,,,percent of total billed charges,,,23.36,,,percent of total billed charges,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.76,,,percent of total billed charges,,,18.9,,,percent of total billed charges,,,,,,,,,,,,,,,9.34,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,23.36,,,percent of total billed charges,,,23.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.87,,,percent of total billed charges,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.14,,,fee schedule,,,23.36,,,percent of total billed charges,,,23.36,,,percent of total billed charges,,,23.36,,,percent of total billed charges,,,,,,,,,16.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.76,,,percent of total billed charges,,
MIDAZOLAM HCL INJ  50MG,2500002176,CDM,636,RC,J2250,HCPCS,7261174910,NDC,496,EAPG,,outpatient,facility,10,ML,23.36,23.36,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE SULF INJ UP TO 10 MG,2500002190,CDM,636,RC,J2270,HCPCS,641612725,NDC,,,,inpatient,facility,1,ML,8.42,8.42,0.67,8.42,,,,,,,,,,,,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.42,,,percent of total billed charges,,,,,,,,,8.42,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.05,,,percent of total billed charges,,,,,,,,,,,,,,,8.42,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,8.42,,,percent of total billed charges,,,4.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.96,,,percent of total billed charges,,
MORPHINE SULF INJ UP TO 10 MG,2500002190,CDM,636,RC,J2270,HCPCS,641612725,NDC,,,,outpatient,facility,1,ML,8.42,8.42,0.67,548.68,,5.97,,,percent of total billed charges,,,2.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.42,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.18,,,fee schedule,,,8.42,,,fee schedule,,,8.42,,,percent of total billed charges,,,,,,,,,8.42,,,percent of total billed charges,,,5.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,4.97,,,percent of total billed charges,,,548.68,,,per diem,,,8.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.42,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.47,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.68,,,percent of total billed charges,,,6.81,,,percent of total billed charges,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8.42,,,percent of total billed charges,,,8.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.67,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,8.42,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.37,,,fee schedule,,,8.42,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,5.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.96,,,percent of total billed charges,,
MORPHINE SULF INJ UP TO 10 MG,2500002190,CDM,636,RC,J2270,HCPCS,641612725,NDC,496,EAPG,,outpatient,facility,1,ML,8.42,8.42,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE 100MG/100ML NACL PRMX,2500002193,CDM,636,RC,J2270,HCPCS,7128620406,NDC,,,,inpatient,facility,100,UN,33,33,2.64,33,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,16.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,17.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.44,,,percent of total billed charges,,
MORPHINE 100MG/100ML NACL PRMX,2500002193,CDM,636,RC,J2270,HCPCS,7128620406,NDC,,,,outpatient,facility,100,UN,33,33,2.64,548.68,,23.4,,,percent of total billed charges,,,8.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,33,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.18,,,fee schedule,,,33,,,fee schedule,,,33,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,20.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,19.47,,,percent of total billed charges,,,548.68,,,per diem,,,33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,33,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.53,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.26,,,percent of total billed charges,,,26.7,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,33,,,percent of total billed charges,,,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.64,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.37,,,fee schedule,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,23.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,19.44,,,percent of total billed charges,,
MORPHINE 100MG/100ML NACL PRMX,2500002193,CDM,636,RC,J2270,HCPCS,7128620406,NDC,496,EAPG,,outpatient,facility,100,UN,33,33,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE SULF INJ 2 MG,2500002198,CDM,636,RC,J2270,HCPCS,409189001,NDC,,,,inpatient,facility,1,ML,7.03,7.03,0.56,7.03,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,7.03,,,percent of total billed charges,,,3.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,5.98,,,percent of total billed charges,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,3.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.14,,,percent of total billed charges,,
MORPHINE SULF INJ 2 MG,2500002198,CDM,636,RC,J2270,HCPCS,409189001,NDC,,,,outpatient,facility,1,ML,7.03,7.03,0.56,548.68,,4.98,,,percent of total billed charges,,,1.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.03,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.18,,,fee schedule,,,7.03,,,fee schedule,,,7.03,,,percent of total billed charges,,,,,,,,,7.03,,,percent of total billed charges,,,4.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,4.15,,,percent of total billed charges,,,548.68,,,per diem,,,7.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.03,,,percent of total billed charges,,,5.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.73,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.74,,,percent of total billed charges,,,5.69,,,percent of total billed charges,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7.03,,,percent of total billed charges,,,7.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.37,,,fee schedule,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,4.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.14,,,percent of total billed charges,,
MORPHINE SULF INJ 2 MG,2500002198,CDM,636,RC,J2270,HCPCS,409189001,NDC,496,EAPG,,outpatient,facility,1,ML,7.03,7.03,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRINE HCL INJ 1 ML,2500002290,CDM,636,RC,J2371,HCPCS,6332375101,NDC,,,,inpatient,facility,1,ML,10.56,10.56,0.84,10.56,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,10.56,,,percent of total billed charges,,,5.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.22,,,percent of total billed charges,,
PHENYLEPHRINE HCL INJ 1 ML,2500002290,CDM,636,RC,J2371,HCPCS,6332375101,NDC,,,,outpatient,facility,1,ML,10.56,10.56,0.84,548.68,,7.49,,,percent of total billed charges,,,2.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.56,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.86,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.56,,,fee schedule,,,10.56,,,percent of total billed charges,,,,,,,,,10.56,,,percent of total billed charges,,,6.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,6.23,,,percent of total billed charges,,,548.68,,,per diem,,,10.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.56,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.12,,,percent of total billed charges,,,8.55,,,percent of total billed charges,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10.56,,,percent of total billed charges,,,10.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.84,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,7.92,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.22,,,percent of total billed charges,,
PHENYLEPHRINE HCL INJ 1 ML,2500002290,CDM,636,RC,J2371,HCPCS,6332375101,NDC,999,EAPG,,outpatient,facility,1,ML,10.56,10.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRINE 100 MG/250 ML,2500002291,CDM,636,RC,J2371,HCPCS,7101926506,NDC,,,,inpatient,facility,250,ML,230.97,230.97,18.48,230.97,,,,,,,,,,,,,,230.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.97,,,percent of total billed charges,,,,,,,,,230.97,,,percent of total billed charges,,,117.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.58,,,percent of total billed charges,,,,,,,,,,,,,,,230.97,,,percent of total billed charges,,,196.32,,,percent of total billed charges,,,,,,,,,,,,,,,230.97,,,percent of total billed charges,,,122.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,230.97,,,percent of total billed charges,,,,,,,,,,,,,,,18.48,,,percent of total billed charges,,,230.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,230.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.09,,,percent of total billed charges,,
PHENYLEPHRINE 100 MG/250 ML,2500002291,CDM,636,RC,J2371,HCPCS,7101926506,NDC,,,,outpatient,facility,250,ML,230.97,230.97,18.48,548.68,,163.78,,,percent of total billed charges,,,56.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,230.97,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,230.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,84.54,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,230.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,230.97,,,fee schedule,,,230.97,,,percent of total billed charges,,,,,,,,,230.97,,,percent of total billed charges,,,141.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,136.27,,,percent of total billed charges,,,548.68,,,per diem,,,230.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,230.97,,,percent of total billed charges,,,196.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,122.67,,,percent of total billed charges,,,230.97,,,percent of total billed charges,,,230.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.81,,,percent of total billed charges,,,186.9,,,percent of total billed charges,,,,,,,,,,,,,,,92.39,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,230.97,,,percent of total billed charges,,,230.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,230.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.48,,,percent of total billed charges,,,230.97,,,percent of total billed charges,,,,,,,,,,,,,,,230.97,,,percent of total billed charges,,,230.97,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,173.23,,,percent of total billed charges,,,230.97,,,percent of total billed charges,,,230.97,,,percent of total billed charges,,,230.97,,,percent of total billed charges,,,,,,,,,161.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,136.09,,,percent of total billed charges,,
PHENYLEPHRINE 100 MG/250 ML,2500002291,CDM,636,RC,J2371,HCPCS,7101926506,NDC,999,EAPG,,outpatient,facility,250,ML,230.97,230.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRINE 50 MG/250 ML,2500002292,CDM,636,RC,J2371,HCPCS,4202321410,NDC,,,,inpatient,facility,250,ML,146.78,146.78,11.74,146.78,,,,,,,,,,,,,,146.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.78,,,percent of total billed charges,,,,,,,,,146.78,,,percent of total billed charges,,,74.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.07,,,percent of total billed charges,,,,,,,,,,,,,,,146.78,,,percent of total billed charges,,,124.76,,,percent of total billed charges,,,,,,,,,,,,,,,146.78,,,percent of total billed charges,,,77.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,146.78,,,percent of total billed charges,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,146.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,146.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.48,,,percent of total billed charges,,
PHENYLEPHRINE 50 MG/250 ML,2500002292,CDM,636,RC,J2371,HCPCS,4202321410,NDC,,,,outpatient,facility,250,ML,146.78,146.78,11.74,548.68,,104.08,,,percent of total billed charges,,,35.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,146.78,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,146.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,53.72,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,146.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,146.78,,,fee schedule,,,146.78,,,percent of total billed charges,,,,,,,,,146.78,,,percent of total billed charges,,,89.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,86.6,,,percent of total billed charges,,,548.68,,,per diem,,,146.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,146.78,,,percent of total billed charges,,,124.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.95,,,percent of total billed charges,,,146.78,,,percent of total billed charges,,,146.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.02,,,percent of total billed charges,,,118.77,,,percent of total billed charges,,,,,,,,,,,,,,,58.71,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,146.78,,,percent of total billed charges,,,146.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,146.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.74,,,percent of total billed charges,,,146.78,,,percent of total billed charges,,,,,,,,,,,,,,,146.78,,,percent of total billed charges,,,146.78,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,110.09,,,percent of total billed charges,,,146.78,,,percent of total billed charges,,,146.78,,,percent of total billed charges,,,146.78,,,percent of total billed charges,,,,,,,,,102.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,86.48,,,percent of total billed charges,,
PHENYLEPHRINE 50 MG/250 ML,2500002292,CDM,636,RC,J2371,HCPCS,4202321410,NDC,999,EAPG,,outpatient,facility,250,ML,146.78,146.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRINE 50MG/5ML IV,2500002296,CDM,636,RC,J2371,HCPCS,6332375101,NDC,,,,inpatient,facility,10,ML,66.96,66.96,5.36,66.96,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,,,,,,,66.96,,,percent of total billed charges,,,34.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.18,,,percent of total billed charges,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,56.92,,,percent of total billed charges,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,35.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,,,,,,,,,,,,,5.36,,,percent of total billed charges,,,66.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.45,,,percent of total billed charges,,
PHENYLEPHRINE 50MG/5ML IV,2500002296,CDM,636,RC,J2371,HCPCS,6332375101,NDC,,,,outpatient,facility,10,ML,66.96,66.96,5.36,548.68,,47.48,,,percent of total billed charges,,,16.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,66.96,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,24.51,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,66.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,66.96,,,fee schedule,,,66.96,,,percent of total billed charges,,,,,,,,,66.96,,,percent of total billed charges,,,41.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,39.51,,,percent of total billed charges,,,548.68,,,per diem,,,66.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,66.96,,,percent of total billed charges,,,56.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.56,,,percent of total billed charges,,,66.96,,,percent of total billed charges,,,66.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.17,,,percent of total billed charges,,,54.18,,,percent of total billed charges,,,,,,,,,,,,,,,26.78,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,66.96,,,percent of total billed charges,,,66.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,66.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.36,,,percent of total billed charges,,,66.96,,,percent of total billed charges,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,66.96,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,50.22,,,percent of total billed charges,,,66.96,,,percent of total billed charges,,,66.96,,,percent of total billed charges,,,66.96,,,percent of total billed charges,,,,,,,,,46.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,39.45,,,percent of total billed charges,,
PHENYLEPHRINE 50MG/5ML IV,2500002296,CDM,636,RC,J2371,HCPCS,6332375101,NDC,999,EAPG,,outpatient,facility,10,ML,66.96,66.96,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRN 1000 MCG/10 ML SYR,2500002297,CDM,636,RC,J2371,HCPCS,6332375101,NDC,,,,inpatient,facility,10,ML,105.6,105.6,8.45,105.6,,,,,,,,,,,,,,105.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.6,,,percent of total billed charges,,,,,,,,,105.6,,,percent of total billed charges,,,53.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.36,,,percent of total billed charges,,,,,,,,,,,,,,,105.6,,,percent of total billed charges,,,89.76,,,percent of total billed charges,,,,,,,,,,,,,,,105.6,,,percent of total billed charges,,,56.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,105.6,,,percent of total billed charges,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,105.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,105.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.22,,,percent of total billed charges,,
PHENYLEPHRN 1000 MCG/10 ML SYR,2500002297,CDM,636,RC,J2371,HCPCS,6332375101,NDC,,,,outpatient,facility,10,ML,105.6,105.6,8.45,548.68,,74.88,,,percent of total billed charges,,,25.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,105.6,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,105.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,38.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,105.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,105.6,,,fee schedule,,,105.6,,,percent of total billed charges,,,,,,,,,105.6,,,percent of total billed charges,,,64.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,62.3,,,percent of total billed charges,,,548.68,,,per diem,,,105.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,105.6,,,percent of total billed charges,,,89.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.08,,,percent of total billed charges,,,105.6,,,percent of total billed charges,,,105.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.24,,,percent of total billed charges,,,85.45,,,percent of total billed charges,,,,,,,,,,,,,,,42.24,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,105.6,,,percent of total billed charges,,,105.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,105.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.45,,,percent of total billed charges,,,105.6,,,percent of total billed charges,,,,,,,,,,,,,,,105.6,,,percent of total billed charges,,,105.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,79.2,,,percent of total billed charges,,,105.6,,,percent of total billed charges,,,105.6,,,percent of total billed charges,,,105.6,,,percent of total billed charges,,,,,,,,,74.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,62.22,,,percent of total billed charges,,
PHENYLEPHRN 1000 MCG/10 ML SYR,2500002297,CDM,636,RC,J2371,HCPCS,6332375101,NDC,999,EAPG,,outpatient,facility,10,ML,105.6,105.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLOROPROCAINE 3  20 ML INJ,2500002305,CDM,636,RC,J2401,HCPCS,6332347827,NDC,,,,inpatient,facility,20,UN,73.85,73.85,5.91,73.85,,,,,,,,,,,,,,73.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.85,,,percent of total billed charges,,,,,,,,,73.85,,,percent of total billed charges,,,37.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.31,,,percent of total billed charges,,,,,,,,,,,,,,,73.85,,,percent of total billed charges,,,62.77,,,percent of total billed charges,,,,,,,,,,,,,,,73.85,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,73.85,,,percent of total billed charges,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,73.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.51,,,percent of total billed charges,,
CHLOROPROCAINE 3  20 ML INJ,2500002305,CDM,636,RC,J2401,HCPCS,6332347827,NDC,,,,outpatient,facility,20,UN,73.85,73.85,0.03,548.68,,52.37,,,percent of total billed charges,,,18.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,73.85,,,percent of total billed charges,,,0.04,,,fee schedule,,,0.04,,,fee schedule,,,,,,,,,0.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,73.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,27.03,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,73.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,73.85,,,fee schedule,,,73.85,,,percent of total billed charges,,,,,,,,,73.85,,,percent of total billed charges,,,45.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,43.57,,,percent of total billed charges,,,548.68,,,per diem,,,73.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,73.85,,,percent of total billed charges,,,62.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.22,,,percent of total billed charges,,,73.85,,,percent of total billed charges,,,73.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.82,,,percent of total billed charges,,,59.76,,,percent of total billed charges,,,,,,,,,,,,,,,29.54,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,73.85,,,percent of total billed charges,,,73.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,73.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.91,,,percent of total billed charges,,,73.85,,,percent of total billed charges,,,,,,,,,,,,,,,73.85,,,percent of total billed charges,,,73.85,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.03,,,fee schedule,,,73.85,,,percent of total billed charges,,,73.85,,,percent of total billed charges,,,73.85,,,percent of total billed charges,,,,,,,,,51.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,43.51,,,percent of total billed charges,,
CHLOROPROCAINE 3  20 ML INJ,2500002305,CDM,636,RC,J2401,HCPCS,6332347827,NDC,435,EAPG,,outpatient,facility,20,UN,73.85,73.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ONDANSETRON 0.8 MG/1 ML ORAL,2500002311,CDM,637,RC,6516269179,NDC,,,,,,inpatient,facility,1,UN,15.84,15.84,1.27,15.84,,,,,,,,,,,,,,15.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.84,,,percent of total billed charges,,,,,,,,,15.84,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,15.84,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,,,,,,,,,,,,,15.84,,,percent of total billed charges,,,8.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,15.84,,,percent of total billed charges,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,15.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.33,,,percent of total billed charges,,
ONDANSETRON 0.8 MG/1 ML ORAL,2500002311,CDM,637,RC,6516269179,NDC,,,,,,outpatient,facility,1,UN,15.84,15.84,1.27,548.68,,11.23,,,percent of total billed charges,,,3.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,15.84,,,percent of total billed charges,,,9.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,11.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,11.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,15.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.8,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,15.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,15.84,,,fee schedule,,,15.84,,,percent of total billed charges,,,,,,,,,15.84,,,percent of total billed charges,,,9.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.29,,,percent of total billed charges,,,,,,,,,,,,,,,8.55,,,percent of total billed charges,,,8.24,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,,,,,,,9.35,,,percent of total billed charges,,,548.68,,,per diem,,,15.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,15.84,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.41,,,percent of total billed charges,,,15.84,,,percent of total billed charges,,,15.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.69,,,percent of total billed charges,,,12.82,,,percent of total billed charges,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,5.86,,,percent of total billed charges,,,5.86,,,percent of total billed charges,,,,,,,,,15.84,,,percent of total billed charges,,,15.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.27,,,percent of total billed charges,,,15.84,,,percent of total billed charges,,,,,,,,,,,,,,,15.84,,,percent of total billed charges,,,15.84,,,percent of total billed charges,,,,,,,,,14.73,,,percent of total billed charges,,,,,,,,,,,,,,,14.73,,,percent of total billed charges,,,14.73,,,percent of total billed charges,,,14.73,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,15.84,,,percent of total billed charges,,,15.84,,,percent of total billed charges,,,15.84,,,percent of total billed charges,,,,,,,,,11.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.33,,,percent of total billed charges,,
ONDANSETRON 0.8 MG/1 ML ORAL,2500002311,CDM,637,RC,6516269179,NDC,999,EAPG,,,,outpatient,facility,1,UN,15.84,15.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PAMIDRONATE INJ 30MG,2500002330,CDM,636,RC,J2430,HCPCS,6745743010,NDC,,,,inpatient,facility,30,UN,320.76,320.76,25.66,320.76,,,,,,,,,,,,,,320.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,320.76,,,percent of total billed charges,,,,,,,,,320.76,,,percent of total billed charges,,,163.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,273.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.46,,,percent of total billed charges,,,,,,,,,,,,,,,320.76,,,percent of total billed charges,,,272.65,,,percent of total billed charges,,,,,,,,,,,,,,,320.76,,,percent of total billed charges,,,170.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,320.76,,,percent of total billed charges,,,,,,,,,,,,,,,25.66,,,percent of total billed charges,,,320.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,320.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.99,,,percent of total billed charges,,
PAMIDRONATE INJ 30MG,2500002330,CDM,636,RC,J2430,HCPCS,6745743010,NDC,,,,outpatient,facility,30,UN,320.76,320.76,12.11,548.68,,14.1,,,fee schedule,,,78.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,320.76,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,320.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,117.4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,16.67,,,fee schedule,,,320.76,,,fee schedule,,,320.76,,,percent of total billed charges,,,,,,,,,320.76,,,percent of total billed charges,,,196.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,189.25,,,percent of total billed charges,,,548.68,,,per diem,,,320.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,320.76,,,percent of total billed charges,,,272.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,170.36,,,percent of total billed charges,,,320.76,,,percent of total billed charges,,,320.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,216.38,,,percent of total billed charges,,,259.56,,,percent of total billed charges,,,,,,,,,,,,,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,320.76,,,percent of total billed charges,,,320.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,320.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.66,,,percent of total billed charges,,,320.76,,,percent of total billed charges,,,,,,,,,,,,,,,320.76,,,percent of total billed charges,,,320.76,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,12.11,,,fee schedule,,,320.76,,,percent of total billed charges,,,320.76,,,percent of total billed charges,,,320.76,,,percent of total billed charges,,,,,,,,,224.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,188.99,,,percent of total billed charges,,
PAMIDRONATE INJ 30MG,2500002330,CDM,636,RC,J2430,HCPCS,6745743010,NDC,435,EAPG,,outpatient,facility,30,UN,320.76,320.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PENICILLIN G K INJ 5000000 U,2500002402,CDM,636,RC,J2540,HCPCS,49052083,NDC,,,,inpatient,facility,5,UN,41.98,41.98,3.36,41.98,,,,,,,,,,,,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.98,,,percent of total billed charges,,,,,,,,,41.98,,,percent of total billed charges,,,21.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.19,,,percent of total billed charges,,,,,,,,,,,,,,,41.98,,,percent of total billed charges,,,35.68,,,percent of total billed charges,,,,,,,,,,,,,,,41.98,,,percent of total billed charges,,,22.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.73,,,percent of total billed charges,,
PENICILLIN G K INJ 5000000 U,2500002402,CDM,636,RC,J2540,HCPCS,49052083,NDC,,,,outpatient,facility,5,UN,41.98,41.98,0.97,548.68,,29.77,,,percent of total billed charges,,,10.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,41.98,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,15.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,41.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,41.98,,,fee schedule,,,41.98,,,percent of total billed charges,,,,,,,,,41.98,,,percent of total billed charges,,,25.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,24.77,,,percent of total billed charges,,,548.68,,,per diem,,,41.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,41.98,,,percent of total billed charges,,,35.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.3,,,percent of total billed charges,,,41.98,,,percent of total billed charges,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.32,,,percent of total billed charges,,,33.97,,,percent of total billed charges,,,,,,,,,,,,,,,16.79,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,41.98,,,percent of total billed charges,,,41.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,41.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.36,,,percent of total billed charges,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,,41.98,,,percent of total billed charges,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.97,,,fee schedule,,,41.98,,,percent of total billed charges,,,41.98,,,percent of total billed charges,,,41.98,,,percent of total billed charges,,,,,,,,,29.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,24.73,,,percent of total billed charges,,
PENICILLIN G K INJ 5000000 U,2500002402,CDM,636,RC,J2540,HCPCS,49052083,NDC,496,EAPG,,outpatient,facility,5,UN,41.98,41.98,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENOBARBITAL INJ UP TO 120 MG,2500002430,CDM,636,RC,J2560,HCPCS,4249441525,NDC,,,,inpatient,facility,1,UN,86.39,86.39,6.91,86.39,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,,,,,,,86.39,,,percent of total billed charges,,,44.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.83,,,percent of total billed charges,,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,73.43,,,percent of total billed charges,,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,45.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,,6.91,,,percent of total billed charges,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.9,,,percent of total billed charges,,
PHENOBARBITAL INJ UP TO 120 MG,2500002430,CDM,636,RC,J2560,HCPCS,4249441525,NDC,,,,outpatient,facility,1,UN,86.39,86.39,3.51,548.68,,61.26,,,percent of total billed charges,,,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,86.39,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,31.62,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.51,,,fee schedule,,,86.39,,,fee schedule,,,86.39,,,percent of total billed charges,,,,,,,,,86.39,,,percent of total billed charges,,,52.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,50.97,,,percent of total billed charges,,,548.68,,,per diem,,,86.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,86.39,,,percent of total billed charges,,,73.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,45.88,,,percent of total billed charges,,,86.39,,,percent of total billed charges,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.28,,,percent of total billed charges,,,69.91,,,percent of total billed charges,,,,,,,,,,,,,,,34.56,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,86.39,,,percent of total billed charges,,,86.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,86.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.91,,,percent of total billed charges,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,86.39,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,34.01,,,fee schedule,,,86.39,,,percent of total billed charges,,,86.39,,,percent of total billed charges,,,86.39,,,percent of total billed charges,,,,,,,,,60.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,50.9,,,percent of total billed charges,,
PHENOBARBITAL INJ UP TO 120 MG,2500002430,CDM,636,RC,J2560,HCPCS,4249441525,NDC,435,EAPG,,outpatient,facility,1,UN,86.39,86.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENOBARBITAL INJ 130 MG,2500002432,CDM,636,RC,J2560,HCPCS,4249441625,NDC,,,,inpatient,facility,1,ML,224.26,224.26,17.94,224.26,,,,,,,,,,,,,,224.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.26,,,percent of total billed charges,,,,,,,,,224.26,,,percent of total billed charges,,,114.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.56,,,percent of total billed charges,,,,,,,,,,,,,,,224.26,,,percent of total billed charges,,,190.62,,,percent of total billed charges,,,,,,,,,,,,,,,224.26,,,percent of total billed charges,,,119.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,224.26,,,percent of total billed charges,,,,,,,,,,,,,,,17.94,,,percent of total billed charges,,,224.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,224.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.13,,,percent of total billed charges,,
PHENOBARBITAL INJ 130 MG,2500002432,CDM,636,RC,J2560,HCPCS,4249441625,NDC,,,,outpatient,facility,1,ML,224.26,224.26,3.51,548.68,,159.02,,,percent of total billed charges,,,54.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,224.26,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,224.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,82.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.51,,,fee schedule,,,224.26,,,fee schedule,,,224.26,,,percent of total billed charges,,,,,,,,,224.26,,,percent of total billed charges,,,137.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,132.31,,,percent of total billed charges,,,548.68,,,per diem,,,224.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,224.26,,,percent of total billed charges,,,190.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.1,,,percent of total billed charges,,,224.26,,,percent of total billed charges,,,224.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.29,,,percent of total billed charges,,,181.47,,,percent of total billed charges,,,,,,,,,,,,,,,89.7,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,224.26,,,percent of total billed charges,,,224.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,224.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.94,,,percent of total billed charges,,,224.26,,,percent of total billed charges,,,,,,,,,,,,,,,224.26,,,percent of total billed charges,,,224.26,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,34.01,,,fee schedule,,,224.26,,,percent of total billed charges,,,224.26,,,percent of total billed charges,,,224.26,,,percent of total billed charges,,,,,,,,,157.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,132.13,,,percent of total billed charges,,
PHENOBARBITAL INJ 130 MG,2500002432,CDM,636,RC,J2560,HCPCS,4249441625,NDC,435,EAPG,,outpatient,facility,1,ML,224.26,224.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYTOCIN IN LR 30 U/500 ML IV,2500002446,CDM,636,RC,J2590,HCPCS,7128560441,NDC,,,,inpatient,facility,500,UN,27.06,27.06,2.16,27.06,,,,,,,,,,,,,,27.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.06,,,percent of total billed charges,,,,,,,,,27.06,,,percent of total billed charges,,,13.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.24,,,percent of total billed charges,,,,,,,,,,,,,,,27.06,,,percent of total billed charges,,,23,,,percent of total billed charges,,,,,,,,,,,,,,,27.06,,,percent of total billed charges,,,14.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,27.06,,,percent of total billed charges,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,27.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.94,,,percent of total billed charges,,
OXYTOCIN IN LR 30 U/500 ML IV,2500002446,CDM,636,RC,J2590,HCPCS,7128560441,NDC,,,,outpatient,facility,500,UN,27.06,27.06,2.16,548.68,,19.19,,,percent of total billed charges,,,6.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,27.06,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,27.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.9,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,27.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,27.06,,,fee schedule,,,27.06,,,percent of total billed charges,,,,,,,,,27.06,,,percent of total billed charges,,,16.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,15.97,,,percent of total billed charges,,,548.68,,,per diem,,,27.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,27.06,,,percent of total billed charges,,,23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.37,,,percent of total billed charges,,,27.06,,,percent of total billed charges,,,27.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.25,,,percent of total billed charges,,,21.9,,,percent of total billed charges,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,27.06,,,percent of total billed charges,,,27.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.16,,,percent of total billed charges,,,27.06,,,percent of total billed charges,,,,,,,,,,,,,,,27.06,,,percent of total billed charges,,,27.06,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,4.69,,,fee schedule,,,27.06,,,percent of total billed charges,,,27.06,,,percent of total billed charges,,,27.06,,,percent of total billed charges,,,,,,,,,18.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15.94,,,percent of total billed charges,,
OXYTOCIN IN LR 30 U/500 ML IV,2500002446,CDM,636,RC,J2590,HCPCS,7128560441,NDC,999,EAPG,,outpatient,facility,500,UN,27.06,27.06,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DESMOPRESSIN ACET INJ 4 MCG,2500002453,CDM,636,RC,J2597,HCPCS,4359893109,NDC,,,,inpatient,facility,1,GR,125.4,125.4,10.03,125.4,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,,,,,,,125.4,,,percent of total billed charges,,,64.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.24,,,percent of total billed charges,,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,106.59,,,percent of total billed charges,,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,66.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.89,,,percent of total billed charges,,
DESMOPRESSIN ACET INJ 4 MCG,2500002453,CDM,636,RC,J2597,HCPCS,4359893109,NDC,,,,outpatient,facility,1,GR,125.4,125.4,5.19,548.68,,88.92,,,percent of total billed charges,,,,,,,,,125.4,,,percent of total billed charges,,,7.22,,,fee schedule,,,6.83,,,fee schedule,,,,,,,,,6.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,125.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,125.4,,,fee schedule,,,125.4,,,percent of total billed charges,,,,,,,,,125.4,,,percent of total billed charges,,,76.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.35,,,percent of total billed charges,,,,,,,,,,,,,,,6.33,,,fee schedule,,,6.33,,,fee schedule,,,6.33,,,fee schedule,,,,,,,,,73.99,,,percent of total billed charges,,,548.68,,,per diem,,,125.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,125.4,,,percent of total billed charges,,,106.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.6,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.59,,,percent of total billed charges,,,101.47,,,percent of total billed charges,,,,,,,,,,,,,,,50.16,,,percent of total billed charges,,,,,,,,,18.7,,,fee schedule,,,13.45,,,fee schedule,,,,,,,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,7.99,,,fee schedule,,,,,,,,,,,,,,,6.92,,,fee schedule,,,9.23,,,fee schedule,,,5.19,,,fee schedule,,,5.78,,,fee schedule,,,125.4,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,87.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,73.89,,,percent of total billed charges,,
DESMOPRESSIN ACET INJ 4 MCG,2500002453,CDM,636,RC,J2597,HCPCS,4359893109,NDC,1440,APC,,outpatient,facility,1,GR,125.4,125.4,4.75,45.9,,,,,,,,5.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,4.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5,,,fee schedule,,,,,,,,,45.9,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,fee schedule,,,,,,,,,,,,,,,5.2,,,fee schedule,,,5.2,,,fee schedule,,,,,,,,,4.95,,,fee schedule,,,4.95,,,fee schedule,,,5.2,,,fee schedule,,,,,,,,,,,,,,,7.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,4.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,fee schedule,,,5.3,,,fee schedule,,,5.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,fee schedule,,,4.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,fee schedule,,,,,,,,,6.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,4.95,,,fee schedule,,,4.95,,,fee schedule,,,,,,,,,,,,,,,4.95,,,fee schedule,,,,,,,,,4.95,,,fee schedule,,,5.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,fee schedule,,,,,,,,,,,,,,,5.15,,,fee schedule,,,4.95,,,fee schedule,,,,,,,,,4.95,,,fee schedule,,,,,,,,,4.95,,,fee schedule,,,5.2,,,fee schedule,,,,,,,,
DESMOPRESSIN ACET INJ 4 MCG,2500002453,CDM,636,RC,J2597,HCPCS,4359893109,NDC,999,EAPG,,outpatient,facility,1,GR,125.4,125.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXACILLIN  SOD 1 GM,2500002520,CDM,636,RC,J2700,HCPCS,5515012715,NDC,,,,inpatient,facility,1,UN,47.85,47.85,3.83,47.85,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,47.85,,,percent of total billed charges,,,24.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.71,,,percent of total billed charges,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,40.67,,,percent of total billed charges,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,25.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.19,,,percent of total billed charges,,
OXACILLIN  SOD 1 GM,2500002520,CDM,636,RC,J2700,HCPCS,5515012715,NDC,,,,outpatient,facility,1,UN,47.85,47.85,0.98,548.68,,33.93,,,percent of total billed charges,,,11.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,47.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,17.51,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,47.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,47.85,,,fee schedule,,,47.85,,,percent of total billed charges,,,,,,,,,47.85,,,percent of total billed charges,,,29.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,28.23,,,percent of total billed charges,,,548.68,,,per diem,,,47.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,47.85,,,percent of total billed charges,,,40.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.41,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.28,,,percent of total billed charges,,,38.72,,,percent of total billed charges,,,,,,,,,,,,,,,19.14,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,47.85,,,percent of total billed charges,,,47.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,47.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.83,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.98,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,,,,,,,33.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,28.19,,,percent of total billed charges,,
OXACILLIN  SOD 1 GM,2500002520,CDM,636,RC,J2700,HCPCS,5515012715,NDC,496,EAPG,,outpatient,facility,1,UN,47.85,47.85,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXACILLIN  SOD INJ 2 GM,2500002522,CDM,636,RC,J2700,HCPCS,5515012824,NDC,,,,inpatient,facility,2,UN,93.32,93.32,7.47,93.32,,,,,,,,,,,,,,93.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.32,,,percent of total billed charges,,,,,,,,,93.32,,,percent of total billed charges,,,47.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.99,,,percent of total billed charges,,,,,,,,,,,,,,,93.32,,,percent of total billed charges,,,79.32,,,percent of total billed charges,,,,,,,,,,,,,,,93.32,,,percent of total billed charges,,,49.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,93.32,,,percent of total billed charges,,,,,,,,,,,,,,,7.47,,,percent of total billed charges,,,93.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.98,,,percent of total billed charges,,
OXACILLIN  SOD INJ 2 GM,2500002522,CDM,636,RC,J2700,HCPCS,5515012824,NDC,,,,outpatient,facility,2,UN,93.32,93.32,0.98,548.68,,66.17,,,percent of total billed charges,,,22.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,93.32,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,93.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,34.16,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,93.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,93.32,,,fee schedule,,,93.32,,,percent of total billed charges,,,,,,,,,93.32,,,percent of total billed charges,,,57.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,55.06,,,percent of total billed charges,,,548.68,,,per diem,,,93.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,93.32,,,percent of total billed charges,,,79.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.56,,,percent of total billed charges,,,93.32,,,percent of total billed charges,,,93.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.95,,,percent of total billed charges,,,75.51,,,percent of total billed charges,,,,,,,,,,,,,,,37.33,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,93.32,,,percent of total billed charges,,,93.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,93.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.47,,,percent of total billed charges,,,93.32,,,percent of total billed charges,,,,,,,,,,,,,,,93.32,,,percent of total billed charges,,,93.32,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.98,,,fee schedule,,,93.32,,,percent of total billed charges,,,93.32,,,percent of total billed charges,,,93.32,,,percent of total billed charges,,,,,,,,,65.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,54.98,,,percent of total billed charges,,
OXACILLIN  SOD INJ 2 GM,2500002522,CDM,636,RC,J2700,HCPCS,5515012824,NDC,496,EAPG,,outpatient,facility,2,UN,93.32,93.32,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOSTIGMINE 1MG/1ML 5ML SYR,2500002535,CDM,636,RC,J2710,HCPCS,7128660651,NDC,,,,inpatient,facility,5,UN,148.5,148.5,11.88,148.5,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,148.5,,,percent of total billed charges,,,75.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,126.22,,,percent of total billed charges,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,78.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.5,,,percent of total billed charges,,
NEOSTIGMINE 1MG/1ML 5ML SYR,2500002535,CDM,636,RC,J2710,HCPCS,7128660651,NDC,,,,outpatient,facility,5,UN,148.5,148.5,0.43,548.68,,105.3,,,percent of total billed charges,,,36.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,148.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,54.35,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,148.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,148.5,,,fee schedule,,,148.5,,,percent of total billed charges,,,,,,,,,148.5,,,percent of total billed charges,,,91.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,87.62,,,percent of total billed charges,,,548.68,,,per diem,,,148.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,148.5,,,percent of total billed charges,,,126.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,78.87,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.18,,,percent of total billed charges,,,120.17,,,percent of total billed charges,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,148.5,,,percent of total billed charges,,,148.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,148.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.88,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.43,,,fee schedule,,,148.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,,,,,,,104.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,87.5,,,percent of total billed charges,,
NEOSTIGMINE 1MG/1ML 5ML SYR,2500002535,CDM,636,RC,J2710,HCPCS,7128660651,NDC,999,EAPG,,outpatient,facility,5,UN,148.5,148.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOSTIGMINE 10 MG INJ,2500002536,CDM,636,RC,J2710,HCPCS,641614910,NDC,,,,inpatient,facility,10,ML,29.7,29.7,2.38,29.7,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,29.7,,,percent of total billed charges,,,15.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,25.24,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,15.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.5,,,percent of total billed charges,,
NEOSTIGMINE 10 MG INJ,2500002536,CDM,636,RC,J2710,HCPCS,641614910,NDC,,,,outpatient,facility,10,ML,29.7,29.7,0.43,548.68,,21.06,,,percent of total billed charges,,,7.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,29.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,29.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,29.7,,,fee schedule,,,29.7,,,percent of total billed charges,,,,,,,,,29.7,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,17.52,,,percent of total billed charges,,,548.68,,,per diem,,,29.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,29.7,,,percent of total billed charges,,,25.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.77,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.04,,,percent of total billed charges,,,24.03,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,29.7,,,percent of total billed charges,,,29.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.38,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.43,,,fee schedule,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,20.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.5,,,percent of total billed charges,,
NEOSTIGMINE 10 MG INJ,2500002536,CDM,636,RC,J2710,HCPCS,641614910,NDC,999,EAPG,,outpatient,facility,10,ML,29.7,29.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROTAMINE SULF INJ  50 MG,2500002542,CDM,636,RC,J2720,HCPCS,6332322905,NDC,,,,inpatient,facility,5,UN,51.08,51.08,4.09,51.08,,,,,,,,,,,,,,51.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.08,,,percent of total billed charges,,,,,,,,,51.08,,,percent of total billed charges,,,26.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,,,,,,,,,,,,,51.08,,,percent of total billed charges,,,43.42,,,percent of total billed charges,,,,,,,,,,,,,,,51.08,,,percent of total billed charges,,,27.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,51.08,,,percent of total billed charges,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,51.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.1,,,percent of total billed charges,,
PROTAMINE SULF INJ  50 MG,2500002542,CDM,636,RC,J2720,HCPCS,6332322905,NDC,,,,outpatient,facility,5,UN,51.08,51.08,0.92,548.68,,36.22,,,percent of total billed charges,,,12.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,51.08,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,51.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,18.7,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,51.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,51.08,,,fee schedule,,,51.08,,,percent of total billed charges,,,,,,,,,51.08,,,percent of total billed charges,,,31.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,30.14,,,percent of total billed charges,,,548.68,,,per diem,,,51.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,51.08,,,percent of total billed charges,,,43.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.13,,,percent of total billed charges,,,51.08,,,percent of total billed charges,,,51.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.46,,,percent of total billed charges,,,41.33,,,percent of total billed charges,,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,51.08,,,percent of total billed charges,,,51.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,51.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.09,,,percent of total billed charges,,,51.08,,,percent of total billed charges,,,,,,,,,,,,,,,51.08,,,percent of total billed charges,,,51.08,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.92,,,fee schedule,,,51.08,,,percent of total billed charges,,,51.08,,,percent of total billed charges,,,51.08,,,percent of total billed charges,,,,,,,,,35.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,30.1,,,percent of total billed charges,,
PROTAMINE SULF INJ  50 MG,2500002542,CDM,636,RC,J2720,HCPCS,6332322905,NDC,999,EAPG,,outpatient,facility,5,UN,51.08,51.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRALATREXATE INJ 20 MG,2500002558,CDM,636,RC,J9307,HCPCS,4881800101,NDC,,,,inpatient,facility,1,ML,22398.81,22398.81,1791.9,22398.81,,,,,,,,,,,,,,22398.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22398.81,,,percent of total billed charges,,,,,,,,,22398.81,,,percent of total billed charges,,,11436.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19077.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13439.29,,,percent of total billed charges,,,,,,,,,,,,,,,22398.81,,,percent of total billed charges,,,19038.99,,,percent of total billed charges,,,,,,,,,,,,,,,22398.81,,,percent of total billed charges,,,11896.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8959.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,22398.81,,,percent of total billed charges,,,,,,,,,,,,,,,1791.9,,,percent of total billed charges,,,22398.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22398.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13197.38,,,percent of total billed charges,,
PRALATREXATE INJ 20 MG,2500002558,CDM,636,RC,J9307,HCPCS,4881800101,NDC,,,,outpatient,facility,1,ML,22398.81,22398.81,188.82,22398.81,,15883,,,percent of total billed charges,,,,,,,,,22398.81,,,percent of total billed charges,,,388.27,,,fee schedule,,,367.33,,,fee schedule,,,,,,,,,367.33,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,22398.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,188.82,,,fee schedule,,,22398.81,,,fee schedule,,,22398.81,,,percent of total billed charges,,,,,,,,,22398.81,,,percent of total billed charges,,,13728.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15959.15,,,percent of total billed charges,,,,,,,,,,,,,,,289.14,,,fee schedule,,,289.14,,,fee schedule,,,289.14,,,fee schedule,,,,,,,,,13215.3,,,percent of total billed charges,,,548.68,,,per diem,,,22398.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,22398.81,,,percent of total billed charges,,,19038.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11896.01,,,percent of total billed charges,,,22398.81,,,percent of total billed charges,,,22398.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15110.24,,,percent of total billed charges,,,18125.12,,,percent of total billed charges,,,,,,,,,,,,,,,8959.52,,,percent of total billed charges,,,,,,,,,788.92,,,fee schedule,,,567.69,,,fee schedule,,,,,,,,,22398.81,,,percent of total billed charges,,,,,,,,,,,,,,,1791.9,,,percent of total billed charges,,,22398.81,,,percent of total billed charges,,,,,,,,,,,,,,,22398.81,,,percent of total billed charges,,,22398.81,,,percent of total billed charges,,,,,,,,,337.14,,,fee schedule,,,,,,,,,,,,,,,292.21,,,fee schedule,,,389.61,,,fee schedule,,,219.14,,,fee schedule,,,310.42,,,fee schedule,,,22398.81,,,percent of total billed charges,,,22398.81,,,percent of total billed charges,,,22398.81,,,percent of total billed charges,,,,,,,,,15703.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11199.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13197.38,,,percent of total billed charges,,
PRALATREXATE INJ 20 MG,2500002558,CDM,636,RC,J9307,HCPCS,4881800101,NDC,9259,APC,,outpatient,facility,1,ML,22398.81,22398.81,358.82,8197.96,,,,,,,,384.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,373.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.51,,,fee schedule,,,,,,,,,8197.96,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,373.77,,,fee schedule,,,,,,,,,,,,,,,392.46,,,fee schedule,,,392.46,,,fee schedule,,,,,,,,,373.77,,,fee schedule,,,373.77,,,fee schedule,,,392.46,,,fee schedule,,,,,,,,,,,,,,,560.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,373.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.82,,,fee schedule,,,399.93,,,fee schedule,,,392.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.77,,,fee schedule,,,373.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,388.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,373.77,,,fee schedule,,,,,,,,,467.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,467.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,373.77,,,fee schedule,,,373.77,,,fee schedule,,,,,,,,,,,,,,,373.77,,,fee schedule,,,,,,,,,373.77,,,fee schedule,,,384.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.77,,,fee schedule,,,,,,,,,,,,,,,388.72,,,fee schedule,,,373.77,,,fee schedule,,,,,,,,,373.77,,,fee schedule,,,,,,,,,373.77,,,fee schedule,,,392.46,,,fee schedule,,,,,,,,
PRALATREXATE INJ 20 MG,2500002558,CDM,636,RC,J9307,HCPCS,4881800101,NDC,463,EAPG,,outpatient,facility,1,ML,22398.81,22398.81,7053.67,10651.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10651.04,,,fee schedule,,,7053.67,,,fee schedule,,,9468.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENTOLAMINE INJ UP TO 5 MG,2500002570,CDM,636,RC,J2760,HCPCS,6809410120,NDC,,,,inpatient,facility,5,UN,1662.41,1662.41,132.99,1662.41,,,,,,,,,,,,,,1662.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.41,,,percent of total billed charges,,,,,,,,,1662.41,,,percent of total billed charges,,,848.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1415.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.45,,,percent of total billed charges,,,,,,,,,,,,,,,1662.41,,,percent of total billed charges,,,1413.05,,,percent of total billed charges,,,,,,,,,,,,,,,1662.41,,,percent of total billed charges,,,882.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.41,,,percent of total billed charges,,,,,,,,,,,,,,,132.99,,,percent of total billed charges,,,1662.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1662.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,979.49,,,percent of total billed charges,,
PHENTOLAMINE INJ UP TO 5 MG,2500002570,CDM,636,RC,J2760,HCPCS,6809410120,NDC,,,,outpatient,facility,5,UN,1662.41,1662.41,65,1662.41,,1178.81,,,percent of total billed charges,,,,,,,,,1662.41,,,percent of total billed charges,,,518.33,,,fee schedule,,,490.38,,,fee schedule,,,,,,,,,490.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1662.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,65,,,fee schedule,,,1662.41,,,fee schedule,,,1662.41,,,percent of total billed charges,,,,,,,,,1662.41,,,percent of total billed charges,,,1018.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1184.47,,,percent of total billed charges,,,,,,,,,,,,,,,446.8,,,fee schedule,,,446.8,,,fee schedule,,,446.8,,,fee schedule,,,,,,,,,980.82,,,percent of total billed charges,,,548.68,,,per diem,,,1662.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1662.41,,,percent of total billed charges,,,1413.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,882.91,,,percent of total billed charges,,,1662.41,,,percent of total billed charges,,,1662.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1121.46,,,percent of total billed charges,,,1345.22,,,percent of total billed charges,,,,,,,,,,,,,,,664.96,,,percent of total billed charges,,,,,,,,,1015.9,,,fee schedule,,,731.01,,,fee schedule,,,,,,,,,1662.41,,,percent of total billed charges,,,,,,,,,,,,,,,132.99,,,percent of total billed charges,,,1662.41,,,percent of total billed charges,,,,,,,,,,,,,,,1662.41,,,percent of total billed charges,,,1662.41,,,percent of total billed charges,,,,,,,,,434.14,,,fee schedule,,,,,,,,,,,,,,,376.28,,,fee schedule,,,501.7,,,fee schedule,,,282.19,,,fee schedule,,,414.4,,,fee schedule,,,1662.41,,,percent of total billed charges,,,1662.41,,,percent of total billed charges,,,1662.41,,,percent of total billed charges,,,,,,,,,1165.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,831.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,979.49,,,percent of total billed charges,,
PHENTOLAMINE INJ UP TO 5 MG,2500002570,CDM,636,RC,J2760,HCPCS,6809410120,NDC,1458,APC,,outpatient,facility,5,UN,1662.41,1662.41,378.84,608.44,,,,,,,,406.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,394.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.58,,,fee schedule,,,,,,,,,608.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,394.63,,,fee schedule,,,,,,,,,,,,,,,414.36,,,fee schedule,,,414.36,,,fee schedule,,,,,,,,,394.63,,,fee schedule,,,394.63,,,fee schedule,,,414.36,,,fee schedule,,,,,,,,,,,,,,,591.94,,,fee schedule,,,,,,,,,,,,,,,,,,,,,394.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,378.84,,,fee schedule,,,422.25,,,fee schedule,,,414.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,394.63,,,fee schedule,,,394.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,410.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,394.63,,,fee schedule,,,,,,,,,493.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,493.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,394.63,,,fee schedule,,,394.63,,,fee schedule,,,,,,,,,,,,,,,394.63,,,fee schedule,,,,,,,,,394.63,,,fee schedule,,,406.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,394.63,,,fee schedule,,,,,,,,,,,,,,,410.42,,,fee schedule,,,394.63,,,fee schedule,,,,,,,,,394.63,,,fee schedule,,,,,,,,,394.63,,,fee schedule,,,414.36,,,fee schedule,,,,,,,,
PHENTOLAMINE INJ UP TO 5 MG,2500002570,CDM,636,RC,J2760,HCPCS,6809410120,NDC,437,EAPG,,outpatient,facility,5,UN,1662.41,1662.41,156.28,235.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.98,,,fee schedule,,,156.28,,,fee schedule,,,209.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.9  SD INJ 10ML,2500002650,CDM,250,RC,6332318610,NDC,,,,,,inpatient,facility,10,UN,3.37,3.37,0.27,3.37,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,3.37,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,
SOD CHLORIDE 0.9  SD INJ 10ML,2500002650,CDM,250,RC,6332318610,NDC,,,,,,outpatient,facility,10,UN,3.37,3.37,0.27,548.68,,2.39,,,percent of total billed charges,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.37,,,percent of total billed charges,,,2.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.37,,,fee schedule,,,3.37,,,percent of total billed charges,,,,,,,,,3.37,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,1.99,,,percent of total billed charges,,,548.68,,,per diem,,,3.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.37,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.79,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.27,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,3.37,,,percent of total billed charges,,,3.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.27,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,2.53,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.99,,,percent of total billed charges,,
SOD CHLORIDE 0.9  SD INJ 10ML,2500002650,CDM,250,RC,6332318610,NDC,999,EAPG,,,,outpatient,facility,10,UN,3.37,3.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPRED SOD SUC 40 MG,2500002660,CDM,636,RC,J2919,HCPCS,9003928,NDC,,,,inpatient,facility,1,UN,21.35,21.35,1.71,21.35,,,,,,,,,,,,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.35,,,percent of total billed charges,,,,,,,,,21.35,,,percent of total billed charges,,,10.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.81,,,percent of total billed charges,,,,,,,,,,,,,,,21.35,,,percent of total billed charges,,,18.15,,,percent of total billed charges,,,,,,,,,,,,,,,21.35,,,percent of total billed charges,,,11.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.58,,,percent of total billed charges,,
METHYLPRED SOD SUC 40 MG,2500002660,CDM,636,RC,J2919,HCPCS,9003928,NDC,,,,outpatient,facility,1,UN,21.35,21.35,0.31,548.68,,15.14,,,percent of total billed charges,,,,,,,,,21.35,,,percent of total billed charges,,,0.39,,,fee schedule,,,0.37,,,fee schedule,,,,,,,,,0.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,21.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,21.35,,,fee schedule,,,21.35,,,percent of total billed charges,,,,,,,,,21.35,,,percent of total billed charges,,,13.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,11.53,,,percent of total billed charges,,,11.1,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,,,,,,,12.6,,,percent of total billed charges,,,548.68,,,per diem,,,21.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,21.35,,,percent of total billed charges,,,18.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.34,,,percent of total billed charges,,,21.35,,,percent of total billed charges,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.4,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,,,,,,,,,,,,,8.54,,,percent of total billed charges,,,,,,,,,7.9,,,percent of total billed charges,,,7.9,,,percent of total billed charges,,,,,,,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,21.35,,,percent of total billed charges,,,21.35,,,percent of total billed charges,,,,,,,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,0.31,,,fee schedule,,,21.35,,,percent of total billed charges,,,21.35,,,percent of total billed charges,,,21.35,,,percent of total billed charges,,,,,,,,,14.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,12.58,,,percent of total billed charges,,
METHYLPRED SOD SUC 40 MG,2500002660,CDM,636,RC,J2919,HCPCS,9003928,NDC,801,APC,,outpatient,facility,1,UN,21.35,21.35,0.26,7.81,,,,,,,,0.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,7.81,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.28,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,fee schedule,,,0.29,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,0.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.28,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,
METHYLPRED SOD SUC 40 MG,2500002660,CDM,636,RC,J2919,HCPCS,9003928,NDC,496,EAPG,,outpatient,facility,1,UN,21.35,21.35,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPRED SOD SUC 125 MG,2500002670,CDM,636,RC,J2919,HCPCS,9004722,NDC,,,,inpatient,facility,2,UN,34.39,34.39,2.75,34.39,,,,,,,,,,,,,,34.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.39,,,percent of total billed charges,,,,,,,,,34.39,,,percent of total billed charges,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.63,,,percent of total billed charges,,,,,,,,,,,,,,,34.39,,,percent of total billed charges,,,29.23,,,percent of total billed charges,,,,,,,,,,,,,,,34.39,,,percent of total billed charges,,,18.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,34.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,,34.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.26,,,percent of total billed charges,,
METHYLPRED SOD SUC 125 MG,2500002670,CDM,636,RC,J2919,HCPCS,9004722,NDC,,,,outpatient,facility,2,UN,34.39,34.39,0.31,548.68,,24.39,,,percent of total billed charges,,,,,,,,,34.39,,,percent of total billed charges,,,0.39,,,fee schedule,,,0.37,,,fee schedule,,,,,,,,,0.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,34.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,34.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,34.39,,,fee schedule,,,34.39,,,percent of total billed charges,,,,,,,,,34.39,,,percent of total billed charges,,,21.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.5,,,percent of total billed charges,,,,,,,,,,,,,,,18.57,,,percent of total billed charges,,,17.88,,,percent of total billed charges,,,18.91,,,percent of total billed charges,,,,,,,,,20.29,,,percent of total billed charges,,,548.68,,,per diem,,,34.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,34.39,,,percent of total billed charges,,,29.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.26,,,percent of total billed charges,,,34.39,,,percent of total billed charges,,,34.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.2,,,percent of total billed charges,,,27.83,,,percent of total billed charges,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,12.72,,,percent of total billed charges,,,12.72,,,percent of total billed charges,,,,,,,,,34.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,,34.39,,,percent of total billed charges,,,,,,,,,,,,,,,34.39,,,percent of total billed charges,,,34.39,,,percent of total billed charges,,,,,,,,,31.99,,,percent of total billed charges,,,,,,,,,,,,,,,31.99,,,percent of total billed charges,,,31.99,,,percent of total billed charges,,,31.99,,,percent of total billed charges,,,0.31,,,fee schedule,,,34.39,,,percent of total billed charges,,,34.39,,,percent of total billed charges,,,34.39,,,percent of total billed charges,,,,,,,,,24.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,20.26,,,percent of total billed charges,,
METHYLPRED SOD SUC 125 MG,2500002670,CDM,636,RC,J2919,HCPCS,9004722,NDC,801,APC,,outpatient,facility,2,UN,34.39,34.39,0.26,12.59,,,,,,,,0.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,12.59,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.28,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,fee schedule,,,0.29,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,0.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.28,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,
METHYLPRED SOD SUC 125 MG,2500002670,CDM,636,RC,J2919,HCPCS,9004722,NDC,496,EAPG,,outpatient,facility,2,UN,34.39,34.39,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPRED SOD SUC 1000 MG,2500002672,CDM,636,RC,J2919,HCPCS,6332326530,NDC,,,,inpatient,facility,1000,UN,112.93,112.93,9.03,112.93,,,,,,,,,,,,,,112.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.93,,,percent of total billed charges,,,,,,,,,112.93,,,percent of total billed charges,,,57.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.76,,,percent of total billed charges,,,,,,,,,,,,,,,112.93,,,percent of total billed charges,,,95.99,,,percent of total billed charges,,,,,,,,,,,,,,,112.93,,,percent of total billed charges,,,59.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,112.93,,,percent of total billed charges,,,,,,,,,,,,,,,9.03,,,percent of total billed charges,,,112.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.54,,,percent of total billed charges,,
METHYLPRED SOD SUC 1000 MG,2500002672,CDM,636,RC,J2919,HCPCS,6332326530,NDC,,,,outpatient,facility,1000,UN,112.93,112.93,0.31,548.68,,80.08,,,percent of total billed charges,,,,,,,,,112.93,,,percent of total billed charges,,,0.39,,,fee schedule,,,0.37,,,fee schedule,,,,,,,,,0.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,112.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,112.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,112.93,,,fee schedule,,,112.93,,,percent of total billed charges,,,,,,,,,112.93,,,percent of total billed charges,,,69.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.46,,,percent of total billed charges,,,,,,,,,,,,,,,60.98,,,percent of total billed charges,,,58.72,,,percent of total billed charges,,,62.11,,,percent of total billed charges,,,,,,,,,66.63,,,percent of total billed charges,,,548.68,,,per diem,,,112.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,112.93,,,percent of total billed charges,,,95.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.98,,,percent of total billed charges,,,112.93,,,percent of total billed charges,,,112.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.18,,,percent of total billed charges,,,91.38,,,percent of total billed charges,,,,,,,,,,,,,,,45.17,,,percent of total billed charges,,,,,,,,,41.78,,,percent of total billed charges,,,41.78,,,percent of total billed charges,,,,,,,,,112.93,,,percent of total billed charges,,,,,,,,,,,,,,,9.03,,,percent of total billed charges,,,112.93,,,percent of total billed charges,,,,,,,,,,,,,,,112.93,,,percent of total billed charges,,,112.93,,,percent of total billed charges,,,,,,,,,105.05,,,percent of total billed charges,,,,,,,,,,,,,,,105.05,,,percent of total billed charges,,,105.05,,,percent of total billed charges,,,105.05,,,percent of total billed charges,,,0.31,,,fee schedule,,,112.93,,,percent of total billed charges,,,112.93,,,percent of total billed charges,,,112.93,,,percent of total billed charges,,,,,,,,,79.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,66.54,,,percent of total billed charges,,
METHYLPRED SOD SUC 1000 MG,2500002672,CDM,636,RC,J2919,HCPCS,6332326530,NDC,801,APC,,outpatient,facility,1000,UN,112.93,112.93,0.26,41.33,,,,,,,,0.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,41.33,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.28,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,fee schedule,,,0.29,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,0.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.27,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,fee schedule,,,,,,,,,,,,,,,0.28,,,fee schedule,,,0.27,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,,,,,,,0.27,,,fee schedule,,,0.28,,,fee schedule,,,,,,,,
METHYLPRED SOD SUC 1000 MG,2500002672,CDM,636,RC,J2919,HCPCS,6332326530,NDC,496,EAPG,,outpatient,facility,1000,UN,112.93,112.93,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL INJ  2 ML (0.1 MG),2500002740,CDM,636,RC,J3010,HCPCS,409909332,NDC,,,,inpatient,facility,2,ML,5.91,5.91,0.47,5.91,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,,,,,,,5.91,,,percent of total billed charges,,,3.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.55,,,percent of total billed charges,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.48,,,percent of total billed charges,,
FENTANYL INJ  2 ML (0.1 MG),2500002740,CDM,636,RC,J3010,HCPCS,409909332,NDC,,,,outpatient,facility,2,ML,5.91,5.91,0.38,548.68,,4.19,,,percent of total billed charges,,,1.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.91,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.16,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.38,,,fee schedule,,,5.91,,,fee schedule,,,5.91,,,percent of total billed charges,,,,,,,,,5.91,,,percent of total billed charges,,,3.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,3.49,,,percent of total billed charges,,,548.68,,,per diem,,,5.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.91,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5.91,,,percent of total billed charges,,,5.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.47,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.87,,,fee schedule,,,5.91,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,5.91,,,percent of total billed charges,,,,,,,,,4.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.48,,,percent of total billed charges,,
FENTANYL INJ  2 ML (0.1 MG),2500002740,CDM,636,RC,J3010,HCPCS,409909332,NDC,496,EAPG,,outpatient,facility,2,ML,5.91,5.91,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL INJ   50ML (2.5 MG),2500002746,CDM,636,RC,J3010,HCPCS,409909461,NDC,,,,inpatient,facility,50,UN,71.84,71.84,5.75,71.84,,,,,,,,,,,,,,71.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.84,,,percent of total billed charges,,,,,,,,,71.84,,,percent of total billed charges,,,36.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.1,,,percent of total billed charges,,,,,,,,,,,,,,,71.84,,,percent of total billed charges,,,61.06,,,percent of total billed charges,,,,,,,,,,,,,,,71.84,,,percent of total billed charges,,,38.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,71.84,,,percent of total billed charges,,,,,,,,,,,,,,,5.75,,,percent of total billed charges,,,71.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.33,,,percent of total billed charges,,
FENTANYL INJ   50ML (2.5 MG),2500002746,CDM,636,RC,J3010,HCPCS,409909461,NDC,,,,outpatient,facility,50,UN,71.84,71.84,0.38,548.68,,50.94,,,percent of total billed charges,,,17.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,71.84,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,71.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,26.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.38,,,fee schedule,,,71.84,,,fee schedule,,,71.84,,,percent of total billed charges,,,,,,,,,71.84,,,percent of total billed charges,,,44.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,42.39,,,percent of total billed charges,,,548.68,,,per diem,,,71.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,71.84,,,percent of total billed charges,,,61.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.15,,,percent of total billed charges,,,71.84,,,percent of total billed charges,,,71.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.46,,,percent of total billed charges,,,58.13,,,percent of total billed charges,,,,,,,,,,,,,,,28.74,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,71.84,,,percent of total billed charges,,,71.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,71.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.75,,,percent of total billed charges,,,71.84,,,percent of total billed charges,,,,,,,,,,,,,,,71.84,,,percent of total billed charges,,,71.84,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.87,,,fee schedule,,,71.84,,,percent of total billed charges,,,71.84,,,percent of total billed charges,,,71.84,,,percent of total billed charges,,,,,,,,,50.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,42.33,,,percent of total billed charges,,
FENTANYL INJ   50ML (2.5 MG),2500002746,CDM,636,RC,J3010,HCPCS,409909461,NDC,496,EAPG,,outpatient,facility,50,UN,71.84,71.84,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUMATRIPTAN SUCC INJ 6 MG,2500002750,CDM,636,RC,J3030,HCPCS,5515017301,NDC,,,,inpatient,facility,0.5,UN,43.56,43.56,3.48,43.56,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,,,,,,,43.56,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.14,,,percent of total billed charges,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,37.03,,,percent of total billed charges,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,3.48,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.67,,,percent of total billed charges,,
SUMATRIPTAN SUCC INJ 6 MG,2500002750,CDM,636,RC,J3030,HCPCS,5515017301,NDC,,,,outpatient,facility,0.5,UN,43.56,43.56,3.48,548.68,,30.89,,,percent of total billed charges,,,10.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,43.56,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,15.94,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,43.56,,,fee schedule,,,43.56,,,fee schedule,,,43.56,,,percent of total billed charges,,,,,,,,,43.56,,,percent of total billed charges,,,26.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,25.7,,,percent of total billed charges,,,548.68,,,per diem,,,43.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,43.56,,,percent of total billed charges,,,37.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.39,,,percent of total billed charges,,,35.25,,,percent of total billed charges,,,,,,,,,,,,,,,17.42,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,43.56,,,percent of total billed charges,,,43.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.48,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,43.56,,,fee schedule,,,43.56,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,,,,,,,30.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,25.67,,,percent of total billed charges,,
SUMATRIPTAN SUCC INJ 6 MG,2500002750,CDM,636,RC,J3030,HCPCS,5515017301,NDC,435,EAPG,,outpatient,facility,0.5,UN,43.56,43.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TERBUTALINE SULF INJ 1 MG,2500002780,CDM,636,RC,J3105,HCPCS,143974610,NDC,,,,inpatient,facility,1,ML,13.2,13.2,1.06,13.2,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,6.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,11.22,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,7.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.78,,,percent of total billed charges,,
TERBUTALINE SULF INJ 1 MG,2500002780,CDM,636,RC,J3105,HCPCS,143974610,NDC,,,,outpatient,facility,1,ML,13.2,13.2,1.06,548.68,,9.36,,,percent of total billed charges,,,3.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.83,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.2,,,fee schedule,,,13.2,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.79,,,percent of total billed charges,,,548.68,,,per diem,,,13.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.2,,,percent of total billed charges,,,11.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.01,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.9,,,percent of total billed charges,,,10.68,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13.2,,,percent of total billed charges,,,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.81,,,fee schedule,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,9.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.78,,,percent of total billed charges,,
TERBUTALINE SULF INJ 1 MG,2500002780,CDM,636,RC,J3105,HCPCS,143974610,NDC,999,EAPG,,outpatient,facility,1,ML,13.2,13.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLORPROMAZINE 10 MG ORAL,2500002834,CDM,636,RC,Q0161,HCPCS,5026816215,NDC,,,,inpatient,facility,10,UN,16.96,16.96,1.36,16.96,,,,,,,,,,,,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.96,,,percent of total billed charges,,,,,,,,,16.96,,,percent of total billed charges,,,8.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.18,,,percent of total billed charges,,,,,,,,,,,,,,,16.96,,,percent of total billed charges,,,14.42,,,percent of total billed charges,,,,,,,,,,,,,,,16.96,,,percent of total billed charges,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.99,,,percent of total billed charges,,
CHLORPROMAZINE 10 MG ORAL,2500002834,CDM,636,RC,Q0161,HCPCS,5026816215,NDC,,,,outpatient,facility,10,UN,16.96,16.96,1.36,548.68,,12.03,,,percent of total billed charges,,,4.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,16.96,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.21,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,16.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,16.96,,,fee schedule,,,16.96,,,percent of total billed charges,,,,,,,,,16.96,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,10.01,,,percent of total billed charges,,,548.68,,,per diem,,,16.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,16.96,,,percent of total billed charges,,,14.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.44,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,6.78,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,16.96,,,percent of total billed charges,,,16.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.36,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,16.96,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,12.72,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,,,,,,,11.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.99,,,percent of total billed charges,,
CHLORPROMAZINE 10 MG ORAL,2500002834,CDM,636,RC,Q0161,HCPCS,5026816215,NDC,999,EAPG,,outpatient,facility,10,UN,16.96,16.96,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLORPROMAZINE 100 MG ORAL,2500002835,CDM,636,RC,Q0161,HCPCS,832030300,NDC,,,,inpatient,facility,100,UN,49.13,49.13,3.93,49.13,,,,,,,,,,,,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.13,,,percent of total billed charges,,,,,,,,,49.13,,,percent of total billed charges,,,25.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.48,,,percent of total billed charges,,,,,,,,,,,,,,,49.13,,,percent of total billed charges,,,41.76,,,percent of total billed charges,,,,,,,,,,,,,,,49.13,,,percent of total billed charges,,,26.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.95,,,percent of total billed charges,,
CHLORPROMAZINE 100 MG ORAL,2500002835,CDM,636,RC,Q0161,HCPCS,832030300,NDC,,,,outpatient,facility,100,UN,49.13,49.13,3.93,548.68,,34.84,,,percent of total billed charges,,,11.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,49.13,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,17.98,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,49.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,49.13,,,fee schedule,,,49.13,,,percent of total billed charges,,,,,,,,,49.13,,,percent of total billed charges,,,30.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,28.99,,,percent of total billed charges,,,548.68,,,per diem,,,49.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,49.13,,,percent of total billed charges,,,41.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.09,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.14,,,percent of total billed charges,,,39.76,,,percent of total billed charges,,,,,,,,,,,,,,,19.65,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,49.13,,,percent of total billed charges,,,49.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,49.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.93,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,,49.13,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,36.85,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,,,,,,,34.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,28.95,,,percent of total billed charges,,
CHLORPROMAZINE 100 MG ORAL,2500002835,CDM,636,RC,Q0161,HCPCS,832030300,NDC,999,EAPG,,outpatient,facility,100,UN,49.13,49.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLORPROMAZINE 25 MG ORAL,2500002836,CDM,637,RC,Q0161,HCPCS,1671404801,NDC,,,,inpatient,facility,25,UN,24.55,24.55,1.96,24.55,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,24.55,,,percent of total billed charges,,,12.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.73,,,percent of total billed charges,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,20.87,,,percent of total billed charges,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.46,,,percent of total billed charges,,
CHLORPROMAZINE 25 MG ORAL,2500002836,CDM,637,RC,Q0161,HCPCS,1671404801,NDC,,,,outpatient,facility,25,UN,24.55,24.55,1.96,548.68,,17.41,,,percent of total billed charges,,,5.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,24.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.99,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,24.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,24.55,,,fee schedule,,,24.55,,,percent of total billed charges,,,,,,,,,24.55,,,percent of total billed charges,,,15.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,14.48,,,percent of total billed charges,,,548.68,,,per diem,,,24.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,24.55,,,percent of total billed charges,,,20.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.56,,,percent of total billed charges,,,19.87,,,percent of total billed charges,,,,,,,,,,,,,,,9.82,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,24.55,,,percent of total billed charges,,,24.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.96,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,18.41,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,17.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.46,,,percent of total billed charges,,
CHLORPROMAZINE 25 MG ORAL,2500002836,CDM,637,RC,Q0161,HCPCS,1671404801,NDC,999,EAPG,,outpatient,facility,25,UN,24.55,24.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THYROTROPIN ALPHA 0.9 MG IM/SC,2500002840,CDM,636,RC,J3240,HCPCS,5846800302,NDC,,,,inpatient,facility,1,ML,12501.72,12501.72,1000.14,12501.72,,,,,,,,,,,,,,12501.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12501.72,,,percent of total billed charges,,,,,,,,,12501.72,,,percent of total billed charges,,,6383.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10647.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7501.03,,,percent of total billed charges,,,,,,,,,,,,,,,12501.72,,,percent of total billed charges,,,10626.46,,,percent of total billed charges,,,,,,,,,,,,,,,12501.72,,,percent of total billed charges,,,6639.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5000.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12501.72,,,percent of total billed charges,,,,,,,,,,,,,,,1000.14,,,percent of total billed charges,,,12501.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12501.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7366.01,,,percent of total billed charges,,
THYROTROPIN ALPHA 0.9 MG IM/SC,2500002840,CDM,636,RC,J3240,HCPCS,5846800302,NDC,,,,outpatient,facility,1,ML,12501.72,12501.72,357.82,12501.72,,8864.97,,,percent of total billed charges,,,,,,,,,12501.72,,,percent of total billed charges,,,2681.46,,,fee schedule,,,2536.85,,,fee schedule,,,,,,,,,2536.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,12501.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1201.26,,,fee schedule,,,12501.72,,,fee schedule,,,12501.72,,,percent of total billed charges,,,,,,,,,12501.72,,,percent of total billed charges,,,7662.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8907.48,,,percent of total billed charges,,,,,,,,,,,,,,,1891.21,,,fee schedule,,,1891.21,,,fee schedule,,,1891.21,,,fee schedule,,,,,,,,,7376.01,,,percent of total billed charges,,,548.68,,,per diem,,,12501.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12501.72,,,percent of total billed charges,,,10626.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6639.66,,,percent of total billed charges,,,12501.72,,,percent of total billed charges,,,12501.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8433.66,,,percent of total billed charges,,,10116.39,,,percent of total billed charges,,,,,,,,,,,,,,,5000.69,,,percent of total billed charges,,,,,,,,,4733.93,,,fee schedule,,,3406.42,,,fee schedule,,,,,,,,,12501.72,,,percent of total billed charges,,,,,,,,,,,,,,,1000.14,,,percent of total billed charges,,,12501.72,,,percent of total billed charges,,,,,,,,,,,,,,,12501.72,,,percent of total billed charges,,,12501.72,,,percent of total billed charges,,,,,,,,,2023.05,,,fee schedule,,,,,,,,,,,,,,,1753.4,,,fee schedule,,,2337.87,,,fee schedule,,,1314.98,,,fee schedule,,,2143.79,,,fee schedule,,,12501.72,,,percent of total billed charges,,,12501.72,,,percent of total billed charges,,,12501.72,,,percent of total billed charges,,,,,,,,,8764.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6250.86,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7366.01,,,percent of total billed charges,,
THYROTROPIN ALPHA 0.9 MG IM/SC,2500002840,CDM,636,RC,J3240,HCPCS,5846800302,NDC,9108,APC,,outpatient,facility,1,ML,12501.72,12501.72,1985.19,4575.63,,,,,,,,2129.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,2067.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2088.59,,,fee schedule,,,,,,,,,4575.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,2067.91,,,fee schedule,,,,,,,,,,,,,,,2171.31,,,fee schedule,,,2171.31,,,fee schedule,,,,,,,,,2067.91,,,fee schedule,,,2067.91,,,fee schedule,,,2171.31,,,fee schedule,,,,,,,,,,,,,,,3101.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2067.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1985.19,,,fee schedule,,,2212.66,,,fee schedule,,,2171.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2067.91,,,fee schedule,,,2067.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2150.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2067.91,,,fee schedule,,,,,,,,,2584.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2584.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,2067.91,,,fee schedule,,,2067.91,,,fee schedule,,,,,,,,,,,,,,,2067.91,,,fee schedule,,,,,,,,,2067.91,,,fee schedule,,,2129.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2067.91,,,fee schedule,,,,,,,,,,,,,,,2150.63,,,fee schedule,,,2067.91,,,fee schedule,,,,,,,,,2067.91,,,fee schedule,,,,,,,,,2067.91,,,fee schedule,,,2171.31,,,fee schedule,,,,,,,,
THYROTROPIN ALPHA 0.9 MG IM/SC,2500002840,CDM,636,RC,J3240,HCPCS,5846800302,NDC,444,EAPG,,outpatient,facility,1,ML,12501.72,12501.72,1304.36,1969.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1969.58,,,fee schedule,,,1304.36,,,fee schedule,,,1750.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATEZOLIZUMAB 840 MG VIAL,2500002849,CDM,636,RC,J9022,HCPCS,5024291801,NDC,,,,inpatient,facility,14,ML,25234.64,25234.64,2018.77,25234.64,,,,,,,,,,,,,,25234.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25234.64,,,percent of total billed charges,,,,,,,,,25234.64,,,percent of total billed charges,,,12884.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21492.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15140.78,,,percent of total billed charges,,,,,,,,,,,,,,,25234.64,,,percent of total billed charges,,,21449.44,,,percent of total billed charges,,,,,,,,,,,,,,,25234.64,,,percent of total billed charges,,,13402.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10093.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,25234.64,,,percent of total billed charges,,,,,,,,,,,,,,,2018.77,,,percent of total billed charges,,,25234.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25234.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14868.25,,,percent of total billed charges,,
ATEZOLIZUMAB 840 MG VIAL,2500002849,CDM,636,RC,J9022,HCPCS,5024291801,NDC,,,,outpatient,facility,14,ML,25234.64,25234.64,56.01,25234.64,,83.94,,,fee schedule,,,,,,,,,25234.64,,,percent of total billed charges,,,111.34,,,fee schedule,,,105.34,,,fee schedule,,,,,,,,,105.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,25234.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,25234.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,25234.64,,,fee schedule,,,25234.64,,,percent of total billed charges,,,,,,,,,25234.64,,,percent of total billed charges,,,15466.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17979.68,,,percent of total billed charges,,,,,,,,,,,,,,,85.01,,,fee schedule,,,85.01,,,fee schedule,,,85.01,,,fee schedule,,,,,,,,,14888.44,,,percent of total billed charges,,,548.68,,,per diem,,,25234.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,25234.64,,,percent of total billed charges,,,21449.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13402.12,,,percent of total billed charges,,,25234.64,,,percent of total billed charges,,,25234.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17023.29,,,percent of total billed charges,,,20419.87,,,percent of total billed charges,,,,,,,,,,,,,,,10093.86,,,percent of total billed charges,,,,,,,,,201.65,,,fee schedule,,,145.1,,,fee schedule,,,,,,,,,25234.64,,,percent of total billed charges,,,,,,,,,,,,,,,2018.77,,,percent of total billed charges,,,25234.64,,,percent of total billed charges,,,,,,,,,,,,,,,25234.64,,,percent of total billed charges,,,25234.64,,,percent of total billed charges,,,,,,,,,86.17,,,fee schedule,,,,,,,,,,,,,,,74.69,,,fee schedule,,,99.58,,,fee schedule,,,56.01,,,fee schedule,,,89.01,,,fee schedule,,,25234.64,,,percent of total billed charges,,,25234.64,,,percent of total billed charges,,,25234.64,,,percent of total billed charges,,,,,,,,,17692.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12617.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14868.25,,,percent of total billed charges,,
ATEZOLIZUMAB 840 MG VIAL,2500002849,CDM,636,RC,J9022,HCPCS,5024291801,NDC,9483,APC,,outpatient,facility,14,ML,25234.64,25234.64,84.69,9235.88,,,,,,,,90.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.1,,,fee schedule,,,,,,,,,9235.88,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,,,,,,,92.63,,,fee schedule,,,92.63,,,fee schedule,,,,,,,,,88.22,,,fee schedule,,,88.22,,,fee schedule,,,92.63,,,fee schedule,,,,,,,,,,,,,,,132.33,,,fee schedule,,,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.69,,,fee schedule,,,94.4,,,fee schedule,,,92.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,88.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,91.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,110.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,110.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,88.22,,,fee schedule,,,88.22,,,fee schedule,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,88.22,,,fee schedule,,,90.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,,,,,,,91.75,,,fee schedule,,,88.22,,,fee schedule,,,,,,,,,88.22,,,fee schedule,,,,,,,,,88.22,,,fee schedule,,,92.63,,,fee schedule,,,,,,,,
ATEZOLIZUMAB 840 MG VIAL,2500002849,CDM,636,RC,J9022,HCPCS,5024291801,NDC,464,EAPG,,outpatient,facility,14,ML,25234.64,25234.64,88.22,133.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.21,,,fee schedule,,,88.22,,,fee schedule,,,118.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,88.22,,,fee schedule,,,88.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIMETHOBENZAMIDE INJ 200 MG,2500002850,CDM,636,RC,J3250,HCPCS,4202311925,NDC,,,,inpatient,facility,2,UN,173.98,173.98,13.92,173.98,,,,,,,,,,,,,,173.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.98,,,percent of total billed charges,,,,,,,,,173.98,,,percent of total billed charges,,,88.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.39,,,percent of total billed charges,,,,,,,,,,,,,,,173.98,,,percent of total billed charges,,,147.88,,,percent of total billed charges,,,,,,,,,,,,,,,173.98,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,173.98,,,percent of total billed charges,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,173.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.51,,,percent of total billed charges,,
TRIMETHOBENZAMIDE INJ 200 MG,2500002850,CDM,636,RC,J3250,HCPCS,4202311925,NDC,,,,outpatient,facility,2,UN,173.98,173.98,6.61,548.68,,123.37,,,percent of total billed charges,,,42.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,173.98,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,173.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,63.68,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.61,,,fee schedule,,,173.98,,,fee schedule,,,173.98,,,percent of total billed charges,,,,,,,,,173.98,,,percent of total billed charges,,,106.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,102.65,,,percent of total billed charges,,,548.68,,,per diem,,,173.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,173.98,,,percent of total billed charges,,,147.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,173.98,,,percent of total billed charges,,,173.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.37,,,percent of total billed charges,,,140.78,,,percent of total billed charges,,,,,,,,,,,,,,,69.59,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,173.98,,,percent of total billed charges,,,173.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,173.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.92,,,percent of total billed charges,,,173.98,,,percent of total billed charges,,,,,,,,,,,,,,,173.98,,,percent of total billed charges,,,173.98,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,50.18,,,fee schedule,,,173.98,,,percent of total billed charges,,,173.98,,,percent of total billed charges,,,173.98,,,percent of total billed charges,,,,,,,,,121.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,102.51,,,percent of total billed charges,,
TRIMETHOBENZAMIDE INJ 200 MG,2500002850,CDM,636,RC,J3250,HCPCS,4202311925,NDC,435,EAPG,,outpatient,facility,2,UN,173.98,173.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TOBRAMYCIN SULF INJ PER 80 MG,2500002860,CDM,636,RC,J3260,HCPCS,6745747322,NDC,,,,inpatient,facility,2,UN,7.85,7.85,0.63,7.85,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,,,,,,,7.85,,,percent of total billed charges,,,4.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.71,,,percent of total billed charges,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,6.67,,,percent of total billed charges,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,4.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,
TOBRAMYCIN SULF INJ PER 80 MG,2500002860,CDM,636,RC,J3260,HCPCS,6745747322,NDC,,,,outpatient,facility,2,UN,7.85,7.85,0.63,548.68,,5.57,,,percent of total billed charges,,,1.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.85,,,fee schedule,,,7.85,,,percent of total billed charges,,,,,,,,,7.85,,,percent of total billed charges,,,4.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,4.63,,,percent of total billed charges,,,548.68,,,per diem,,,7.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.85,,,percent of total billed charges,,,6.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.17,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.3,,,percent of total billed charges,,,6.35,,,percent of total billed charges,,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7.85,,,percent of total billed charges,,,7.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.63,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.48,,,fee schedule,,,7.85,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,5.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.63,,,percent of total billed charges,,
TOBRAMYCIN SULF INJ PER 80 MG,2500002860,CDM,636,RC,J3260,HCPCS,6745747322,NDC,999,EAPG,,outpatient,facility,2,UN,7.85,7.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SP-FERUMOXYTOL 510 MG INJ,2500002877,CDM,636,RC,5933877510,NDC,,,,,,inpatient,facility,17,GR,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-FERUMOXYTOL 510 MG INJ,2500002877,CDM,636,RC,5933877510,NDC,,,,,,outpatient,facility,17,GR,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-FERUMOXYTOL 510 MG INJ,2500002877,CDM,636,RC,5933877510,NDC,999,EAPG,,,,outpatient,facility,17,GR,0.01,0.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Romiplostim 125  mcg vial,2500002878,CDM,636,RC,J2796,HCPCS,5551322301,NDC,,,,inpatient,facility,125,UN,4132.03,4132.03,330.56,4132.03,,,,,,,,,,,,,,4132.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4132.03,,,percent of total billed charges,,,,,,,,,4132.03,,,percent of total billed charges,,,2109.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3519.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2479.22,,,percent of total billed charges,,,,,,,,,,,,,,,4132.03,,,percent of total billed charges,,,3512.23,,,percent of total billed charges,,,,,,,,,,,,,,,4132.03,,,percent of total billed charges,,,2194.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1652.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4132.03,,,percent of total billed charges,,,,,,,,,,,,,,,330.56,,,percent of total billed charges,,,4132.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4132.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2434.59,,,percent of total billed charges,,
Romiplostim 125  mcg vial,2500002878,CDM,636,RC,J2796,HCPCS,5551322301,NDC,,,,outpatient,facility,125,UN,4132.03,4132.03,52.58,4132.03,,2930.02,,,percent of total billed charges,,,1008.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4132.03,,,percent of total billed charges,,,130.85,,,fee schedule,,,123.79,,,fee schedule,,,,,,,,,123.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4132.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1512.32,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,52.58,,,fee schedule,,,4132.03,,,fee schedule,,,4132.03,,,percent of total billed charges,,,,,,,,,4132.03,,,percent of total billed charges,,,2532.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2944.07,,,percent of total billed charges,,,,,,,,,,,,,,,96.03,,,fee schedule,,,96.03,,,fee schedule,,,96.03,,,fee schedule,,,,,,,,,2437.9,,,percent of total billed charges,,,548.68,,,per diem,,,4132.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4132.03,,,percent of total billed charges,,,3512.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2194.52,,,percent of total billed charges,,,4132.03,,,percent of total billed charges,,,4132.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.47,,,percent of total billed charges,,,3343.64,,,percent of total billed charges,,,,,,,,,,,,,,,1652.81,,,percent of total billed charges,,,,,,,,,218.67,,,fee schedule,,,157.35,,,fee schedule,,,,,,,,,4132.03,,,percent of total billed charges,,,4132.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4132.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,330.56,,,percent of total billed charges,,,4132.03,,,percent of total billed charges,,,,,,,,,,,,,,,4132.03,,,percent of total billed charges,,,4132.03,,,percent of total billed charges,,,,,,,,,93.45,,,fee schedule,,,,,,,,,,,,,,,80.99,,,fee schedule,,,107.99,,,fee schedule,,,60.74,,,fee schedule,,,104.62,,,fee schedule,,,4132.03,,,percent of total billed charges,,,4132.03,,,percent of total billed charges,,,4132.03,,,percent of total billed charges,,,,,,,,,2896.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2066.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2434.59,,,percent of total billed charges,,
Romiplostim 125  mcg vial,2500002878,CDM,636,RC,J2796,HCPCS,5551322301,NDC,999,EAPG,,outpatient,facility,125,UN,4132.03,4132.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Enfortumab Vedotin-EJFV 20mg,2500002882,CDM,636,RC,J9177,HCPCS,5114402001,NDC,,,,inpatient,facility,20,UN,9269.7,9269.7,741.58,9269.7,,,,,,,,,,,,,,9269.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9269.7,,,percent of total billed charges,,,,,,,,,9269.7,,,percent of total billed charges,,,4733.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7895,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5561.82,,,percent of total billed charges,,,,,,,,,,,,,,,9269.7,,,percent of total billed charges,,,7879.25,,,percent of total billed charges,,,,,,,,,,,,,,,9269.7,,,percent of total billed charges,,,4923.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3707.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9269.7,,,percent of total billed charges,,,,,,,,,,,,,,,741.58,,,percent of total billed charges,,,9269.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9269.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5461.71,,,percent of total billed charges,,
Enfortumab Vedotin-EJFV 20mg,2500002882,CDM,636,RC,J9177,HCPCS,5114402001,NDC,,,,outpatient,facility,20,UN,9269.7,9269.7,22.22,9269.7,,36.2,,,fee schedule,,,,,,,,,9269.7,,,percent of total billed charges,,,46.88,,,fee schedule,,,44.36,,,fee schedule,,,,,,,,,44.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,9269.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9269.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9269.7,,,fee schedule,,,9269.7,,,percent of total billed charges,,,,,,,,,9269.7,,,percent of total billed charges,,,5681.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6604.66,,,percent of total billed charges,,,,,,,,,,,,,,,35.03,,,fee schedule,,,35.03,,,fee schedule,,,35.03,,,fee schedule,,,,,,,,,5469.12,,,percent of total billed charges,,,548.68,,,per diem,,,9269.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9269.7,,,percent of total billed charges,,,7879.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4923.14,,,percent of total billed charges,,,9269.7,,,percent of total billed charges,,,9269.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6253.34,,,percent of total billed charges,,,7501.04,,,percent of total billed charges,,,,,,,,,,,,,,,3707.88,,,percent of total billed charges,,,,,,,,,79.98,,,fee schedule,,,57.55,,,fee schedule,,,,,,,,,9269.7,,,percent of total billed charges,,,,,,,,,,,,,,,741.58,,,percent of total billed charges,,,9269.7,,,percent of total billed charges,,,,,,,,,,,,,,,9269.7,,,percent of total billed charges,,,9269.7,,,percent of total billed charges,,,,,,,,,34.18,,,fee schedule,,,,,,,,,,,,,,,29.63,,,fee schedule,,,39.5,,,fee schedule,,,22.22,,,fee schedule,,,37.48,,,fee schedule,,,9269.7,,,percent of total billed charges,,,9269.7,,,percent of total billed charges,,,9269.7,,,percent of total billed charges,,,,,,,,,6498.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4634.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5461.71,,,percent of total billed charges,,
Enfortumab Vedotin-EJFV 20mg,2500002882,CDM,636,RC,J9177,HCPCS,5114402001,NDC,9364,APC,,outpatient,facility,20,UN,9269.7,9269.7,35.18,3392.71,,,,,,,,37.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,36.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.02,,,fee schedule,,,,,,,,,3392.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,36.65,,,fee schedule,,,,,,,,,,,,,,,38.48,,,fee schedule,,,38.48,,,fee schedule,,,,,,,,,36.65,,,fee schedule,,,36.65,,,fee schedule,,,38.48,,,fee schedule,,,,,,,,,,,,,,,54.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,36.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.18,,,fee schedule,,,39.22,,,fee schedule,,,38.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.65,,,fee schedule,,,36.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,38.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,36.65,,,fee schedule,,,,,,,,,45.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,45.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,36.65,,,fee schedule,,,36.65,,,fee schedule,,,,,,,,,,,,,,,36.65,,,fee schedule,,,,,,,,,36.65,,,fee schedule,,,37.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.65,,,fee schedule,,,,,,,,,,,,,,,38.12,,,fee schedule,,,36.65,,,fee schedule,,,,,,,,,36.65,,,fee schedule,,,,,,,,,36.65,,,fee schedule,,,38.48,,,fee schedule,,,,,,,,
Enfortumab Vedotin-EJFV 20mg,2500002882,CDM,636,RC,J9177,HCPCS,5114402001,NDC,463,EAPG,,outpatient,facility,20,UN,9269.7,9269.7,7053.67,10651.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10651.04,,,fee schedule,,,7053.67,,,fee schedule,,,9468.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIPTORELIN PAMOATE 22.5 MG,2500002891,CDM,636,RC,J3315,HCPCS,7467659061,NDC,,,,inpatient,facility,22.5,UN,17068.29,17068.29,1365.46,17068.29,,,,,,,,,,,,,,17068.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17068.29,,,percent of total billed charges,,,,,,,,,17068.29,,,percent of total billed charges,,,8715.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14537.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10240.97,,,percent of total billed charges,,,,,,,,,,,,,,,17068.29,,,percent of total billed charges,,,14508.05,,,percent of total billed charges,,,,,,,,,,,,,,,17068.29,,,percent of total billed charges,,,9064.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6827.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,17068.29,,,percent of total billed charges,,,,,,,,,,,,,,,1365.46,,,percent of total billed charges,,,17068.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17068.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10056.64,,,percent of total billed charges,,
TRIPTORELIN PAMOATE 22.5 MG,2500002891,CDM,636,RC,J3315,HCPCS,7467659061,NDC,,,,outpatient,facility,22.5,UN,17068.29,17068.29,255.11,17068.29,,12103.12,,,percent of total billed charges,,,,,,,,,17068.29,,,percent of total billed charges,,,595.15,,,fee schedule,,,563.05,,,fee schedule,,,,,,,,,563.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,17068.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,17068.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,17068.29,,,fee schedule,,,17068.29,,,percent of total billed charges,,,,,,,,,17068.29,,,percent of total billed charges,,,10461.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12161.16,,,percent of total billed charges,,,,,,,,,,,,,,,413.59,,,fee schedule,,,413.59,,,fee schedule,,,413.59,,,fee schedule,,,,,,,,,10070.29,,,percent of total billed charges,,,548.68,,,per diem,,,17068.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,17068.29,,,percent of total billed charges,,,14508.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9064.97,,,percent of total billed charges,,,17068.29,,,percent of total billed charges,,,17068.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11514.27,,,percent of total billed charges,,,13811.66,,,percent of total billed charges,,,,,,,,,,,,,,,6827.32,,,percent of total billed charges,,,,,,,,,918.4,,,fee schedule,,,660.86,,,fee schedule,,,,,,,,,17068.29,,,percent of total billed charges,,,,,,,,,,,,,,,1365.46,,,percent of total billed charges,,,17068.29,,,percent of total billed charges,,,,,,,,,,,,,,,17068.29,,,percent of total billed charges,,,17068.29,,,percent of total billed charges,,,,,,,,,392.48,,,fee schedule,,,,,,,,,,,,,,,340.17,,,fee schedule,,,453.56,,,fee schedule,,,255.11,,,fee schedule,,,475.82,,,fee schedule,,,17068.29,,,percent of total billed charges,,,17068.29,,,percent of total billed charges,,,17068.29,,,percent of total billed charges,,,,,,,,,11966.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8534.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10056.64,,,percent of total billed charges,,
TRIPTORELIN PAMOATE 22.5 MG,2500002891,CDM,636,RC,J3315,HCPCS,7467659061,NDC,9122,APC,,outpatient,facility,22.5,UN,17068.29,17068.29,462.04,6246.99,,,,,,,,495.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,481.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,486.1,,,fee schedule,,,,,,,,,6246.99,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,481.29,,,fee schedule,,,,,,,,,,,,,,,505.35,,,fee schedule,,,505.35,,,fee schedule,,,,,,,,,481.29,,,fee schedule,,,481.29,,,fee schedule,,,505.35,,,fee schedule,,,,,,,,,,,,,,,721.94,,,fee schedule,,,,,,,,,,,,,,,,,,,,,481.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462.04,,,fee schedule,,,514.98,,,fee schedule,,,505.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,481.29,,,fee schedule,,,481.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,500.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,481.29,,,fee schedule,,,,,,,,,601.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,601.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,481.29,,,fee schedule,,,481.29,,,fee schedule,,,,,,,,,,,,,,,481.29,,,fee schedule,,,,,,,,,481.29,,,fee schedule,,,495.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,481.29,,,fee schedule,,,,,,,,,,,,,,,500.54,,,fee schedule,,,481.29,,,fee schedule,,,,,,,,,481.29,,,fee schedule,,,,,,,,,481.29,,,fee schedule,,,505.35,,,fee schedule,,,,,,,,
TRIPTORELIN PAMOATE 22.5 MG,2500002891,CDM,636,RC,J3315,HCPCS,7467659061,NDC,441,EAPG,,outpatient,facility,22.5,UN,17068.29,17068.29,878.39,1326.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1326.37,,,fee schedule,,,878.39,,,fee schedule,,,1179.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.39,,,fee schedule,,,878.39,,,fee schedule,,,878.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,878.39,,,fee schedule,,,,,,,,,,,,,,,878.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SP-(R)TBO-FILGRASTIM 300MCG 0.,2500002893,CDM,636,RC,J1447,HCPCS,6345991011,NDC,,,,inpatient,facility,0.5,UN,0.03,0.03,0.01,0.03,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,0.03,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,
SP-(R)TBO-FILGRASTIM 300MCG 0.,2500002893,CDM,636,RC,J1447,HCPCS,6345991011,NDC,,,,outpatient,facility,0.5,UN,0.03,0.03,0.01,548.68,,0.41,,,fee schedule,,,,,,,,,0.03,,,percent of total billed charges,,,0.52,,,fee schedule,,,0.49,,,fee schedule,,,,,,,,,0.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.03,,,fee schedule,,,0.03,,,percent of total billed charges,,,,,,,,,0.03,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,fee schedule,,,0.03,,,fee schedule,,,0.03,,,fee schedule,,,,,,,,,0.02,,,percent of total billed charges,,,548.68,,,per diem,,,0.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.03,,,fee schedule,,,0.03,,,fee schedule,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,0.03,,,fee schedule,,,,,,,,,,,,,,,0.03,,,fee schedule,,,0.03,,,fee schedule,,,0.03,,,fee schedule,,,0.03,,,fee schedule,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.02,,,percent of total billed charges,,
SP-(R)TBO-FILGRASTIM 300MCG 0.,2500002893,CDM,636,RC,J1447,HCPCS,6345991011,NDC,1748,APC,,outpatient,facility,0.5,UN,0.03,0.03,0.01,0.6,,,,,,,,0.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,0.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.42,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,0.4,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,,,,,,,,0.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,fee schedule,,,0.43,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.4,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,0.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.42,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,
SP-(R)TBO-FILGRASTIM 300MCG 0.,2500002893,CDM,636,RC,J1447,HCPCS,6345991011,NDC,438,EAPG,,outpatient,facility,0.5,UN,0.03,0.03,332.92,502.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,502.71,,,fee schedule,,,332.92,,,fee schedule,,,446.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Fam/TrasTzumb/drxtcn-nxki 100,2500002896,CDM,636,RC,J9358,HCPCS,6559740601,NDC,,,,inpatient,facility,100,UN,9267.62,9267.62,741.41,9267.62,,,,,,,,,,,,,,9267.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9267.62,,,percent of total billed charges,,,,,,,,,9267.62,,,percent of total billed charges,,,4732.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7893.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5560.57,,,percent of total billed charges,,,,,,,,,,,,,,,9267.62,,,percent of total billed charges,,,7877.48,,,percent of total billed charges,,,,,,,,,,,,,,,9267.62,,,percent of total billed charges,,,4922.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3707.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9267.62,,,percent of total billed charges,,,,,,,,,,,,,,,741.41,,,percent of total billed charges,,,9267.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9267.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5460.48,,,percent of total billed charges,,
Fam/TrasTzumb/drxtcn-nxki 100,2500002896,CDM,636,RC,J9358,HCPCS,6559740601,NDC,,,,outpatient,facility,100,UN,9267.62,9267.62,17.21,9267.62,,27.27,,,fee schedule,,,,,,,,,9267.62,,,percent of total billed charges,,,36.02,,,fee schedule,,,34.08,,,fee schedule,,,,,,,,,34.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,9267.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9267.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9267.62,,,fee schedule,,,9267.62,,,percent of total billed charges,,,,,,,,,9267.62,,,percent of total billed charges,,,5680.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6603.18,,,percent of total billed charges,,,,,,,,,,,,,,,27.24,,,fee schedule,,,27.24,,,fee schedule,,,27.24,,,fee schedule,,,,,,,,,5467.9,,,percent of total billed charges,,,548.68,,,per diem,,,9267.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9267.62,,,percent of total billed charges,,,7877.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4922.03,,,percent of total billed charges,,,9267.62,,,percent of total billed charges,,,9267.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6251.94,,,percent of total billed charges,,,7499.36,,,percent of total billed charges,,,,,,,,,,,,,,,3707.05,,,percent of total billed charges,,,,,,,,,61.94,,,fee schedule,,,44.57,,,fee schedule,,,,,,,,,9267.62,,,percent of total billed charges,,,,,,,,,,,,,,,741.41,,,percent of total billed charges,,,9267.62,,,percent of total billed charges,,,,,,,,,,,,,,,9267.62,,,percent of total billed charges,,,9267.62,,,percent of total billed charges,,,,,,,,,26.47,,,fee schedule,,,,,,,,,,,,,,,22.94,,,fee schedule,,,30.59,,,fee schedule,,,17.21,,,fee schedule,,,28.8,,,fee schedule,,,9267.62,,,percent of total billed charges,,,9267.62,,,percent of total billed charges,,,9267.62,,,percent of total billed charges,,,,,,,,,6497.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4633.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5460.48,,,percent of total billed charges,,
Fam/TrasTzumb/drxtcn-nxki 100,2500002896,CDM,636,RC,J9358,HCPCS,6559740601,NDC,9353,APC,,outpatient,facility,100,UN,9267.62,9267.62,27.66,3391.95,,,,,,,,29.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,28.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.1,,,fee schedule,,,,,,,,,3391.95,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,28.81,,,fee schedule,,,,,,,,,,,,,,,30.25,,,fee schedule,,,30.25,,,fee schedule,,,,,,,,,28.81,,,fee schedule,,,28.81,,,fee schedule,,,30.25,,,fee schedule,,,,,,,,,,,,,,,43.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,28.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,30.83,,,fee schedule,,,30.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.81,,,fee schedule,,,28.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,29.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,28.81,,,fee schedule,,,,,,,,,36.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,36.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,28.81,,,fee schedule,,,28.81,,,fee schedule,,,,,,,,,,,,,,,28.81,,,fee schedule,,,,,,,,,28.81,,,fee schedule,,,29.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.81,,,fee schedule,,,,,,,,,,,,,,,29.96,,,fee schedule,,,28.81,,,fee schedule,,,,,,,,,28.81,,,fee schedule,,,,,,,,,28.81,,,fee schedule,,,30.25,,,fee schedule,,,,,,,,
Fam/TrasTzumb/drxtcn-nxki 100,2500002896,CDM,636,RC,J9358,HCPCS,6559740601,NDC,461,EAPG,,outpatient,facility,100,UN,9267.62,9267.62,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LABETALOL 400 MG/80 ML INJ,2500002901,CDM,250,RC,143962301,NDC,,,,,,inpatient,facility,80,UN,92.4,92.4,7.39,92.4,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,,,,,92.4,,,percent of total billed charges,,,47.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,78.54,,,percent of total billed charges,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,49.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.44,,,percent of total billed charges,,
LABETALOL 400 MG/80 ML INJ,2500002901,CDM,250,RC,143962301,NDC,,,,,,outpatient,facility,80,UN,92.4,92.4,7.39,548.68,,65.52,,,percent of total billed charges,,,22.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,92.4,,,percent of total billed charges,,,57.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,64.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,64.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,33.82,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,92.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,92.4,,,fee schedule,,,92.4,,,percent of total billed charges,,,,,,,,,92.4,,,percent of total billed charges,,,56.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,54.52,,,percent of total billed charges,,,548.68,,,per diem,,,92.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,92.4,,,percent of total billed charges,,,78.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.07,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.33,,,percent of total billed charges,,,74.77,,,percent of total billed charges,,,,,,,,,,,,,,,36.96,,,percent of total billed charges,,,,,,,,,36.96,,,percent of total billed charges,,,36.96,,,percent of total billed charges,,,,,,,,,92.4,,,percent of total billed charges,,,92.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,92.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.39,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,,,,,,,36.96,,,percent of total billed charges,,,,,,,,,,,,,,,36.96,,,percent of total billed charges,,,36.96,,,percent of total billed charges,,,36.96,,,percent of total billed charges,,,69.3,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,,,,,,,64.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,54.44,,,percent of total billed charges,,
LABETALOL 400 MG/80 ML INJ,2500002901,CDM,250,RC,143962301,NDC,999,EAPG,,,,outpatient,facility,80,UN,92.4,92.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIAMCINOLONE ACET INJ 40 MG,2500002906,CDM,636,RC,J3301,HCPCS,703024101,NDC,,,,inpatient,facility,1,ML,32.04,32.04,2.56,32.04,,,,,,,,,,,,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.04,,,percent of total billed charges,,,,,,,,,32.04,,,percent of total billed charges,,,16.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.22,,,percent of total billed charges,,,,,,,,,,,,,,,32.04,,,percent of total billed charges,,,27.23,,,percent of total billed charges,,,,,,,,,,,,,,,32.04,,,percent of total billed charges,,,17.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.88,,,percent of total billed charges,,
TRIAMCINOLONE ACET INJ 40 MG,2500002906,CDM,636,RC,J3301,HCPCS,703024101,NDC,,,,outpatient,facility,1,ML,32.04,32.04,1.07,548.68,,22.72,,,percent of total billed charges,,,7.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,32.04,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.87,,,fee schedule,,,32.04,,,fee schedule,,,32.04,,,percent of total billed charges,,,,,,,,,32.04,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,18.9,,,percent of total billed charges,,,548.68,,,per diem,,,32.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,32.04,,,percent of total billed charges,,,27.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.02,,,percent of total billed charges,,,32.04,,,percent of total billed charges,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.61,,,percent of total billed charges,,,25.93,,,percent of total billed charges,,,,,,,,,,,,,,,12.82,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,32.04,,,percent of total billed charges,,,32.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,32.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.56,,,percent of total billed charges,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,32.04,,,percent of total billed charges,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.07,,,fee schedule,,,32.04,,,percent of total billed charges,,,32.04,,,percent of total billed charges,,,32.04,,,percent of total billed charges,,,,,,,,,22.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.88,,,percent of total billed charges,,
TRIAMCINOLONE ACET INJ 40 MG,2500002906,CDM,636,RC,J3301,HCPCS,703024101,NDC,496,EAPG,,outpatient,facility,1,ML,32.04,32.04,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPINEPHrine/NS 8 MG/250 ML BAG,2500002908,CDM,636,RC,J0171,HCPCS,7101907101,NDC,,,,inpatient,facility,250,UN,314.75,314.75,25.18,314.75,,,,,,,,,,,,,,314.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,314.75,,,percent of total billed charges,,,,,,,,,314.75,,,percent of total billed charges,,,160.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,268.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.85,,,percent of total billed charges,,,,,,,,,,,,,,,314.75,,,percent of total billed charges,,,267.54,,,percent of total billed charges,,,,,,,,,,,,,,,314.75,,,percent of total billed charges,,,167.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,314.75,,,percent of total billed charges,,,,,,,,,,,,,,,25.18,,,percent of total billed charges,,,314.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,314.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.45,,,percent of total billed charges,,
EPINEPHrine/NS 8 MG/250 ML BAG,2500002908,CDM,636,RC,J0171,HCPCS,7101907101,NDC,,,,outpatient,facility,250,UN,314.75,314.75,0.49,548.68,,223.19,,,percent of total billed charges,,,76.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,314.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,314.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,115.2,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.49,,,fee schedule,,,314.75,,,fee schedule,,,314.75,,,percent of total billed charges,,,,,,,,,314.75,,,percent of total billed charges,,,192.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,185.7,,,percent of total billed charges,,,548.68,,,per diem,,,314.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,314.75,,,percent of total billed charges,,,267.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,167.16,,,percent of total billed charges,,,314.75,,,percent of total billed charges,,,314.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,212.33,,,percent of total billed charges,,,254.7,,,percent of total billed charges,,,,,,,,,,,,,,,125.9,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,314.75,,,percent of total billed charges,,,314.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,314.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.18,,,percent of total billed charges,,,314.75,,,percent of total billed charges,,,,,,,,,,,,,,,314.75,,,percent of total billed charges,,,314.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.84,,,fee schedule,,,314.75,,,percent of total billed charges,,,314.75,,,percent of total billed charges,,,314.75,,,percent of total billed charges,,,,,,,,,220.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,185.45,,,percent of total billed charges,,
EPINEPHrine/NS 8 MG/250 ML BAG,2500002908,CDM,636,RC,J0171,HCPCS,7101907101,NDC,496,EAPG,,outpatient,facility,250,UN,314.75,314.75,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REMDESIVIR 100 MG/20 ML INJ,2500002921,CDM,636,RC,J0248,HCPCS,6195829021,NDC,,,,inpatient,facility,20,UN,1716,1716,137.28,1716,,,,,,,,,,,,,,1716,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1716,,,percent of total billed charges,,,,,,,,,1716,,,percent of total billed charges,,,876.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1461.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1029.6,,,percent of total billed charges,,,,,,,,,,,,,,,1716,,,percent of total billed charges,,,1458.6,,,percent of total billed charges,,,,,,,,,,,,,,,1716,,,percent of total billed charges,,,911.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,686.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1716,,,percent of total billed charges,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,,1716,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1716,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1011.07,,,percent of total billed charges,,
REMDESIVIR 100 MG/20 ML INJ,2500002921,CDM,636,RC,J0248,HCPCS,6195829021,NDC,,,,outpatient,facility,20,UN,1716,1716,3.76,1716,,1216.82,,,percent of total billed charges,,,,,,,,,1716,,,percent of total billed charges,,,7.15,,,fee schedule,,,6.77,,,fee schedule,,,,,,,,,6.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1716,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1716,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1716,,,fee schedule,,,1716,,,percent of total billed charges,,,,,,,,,1716,,,percent of total billed charges,,,1051.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1222.65,,,percent of total billed charges,,,,,,,,,,,,,,,6.06,,,fee schedule,,,6.06,,,fee schedule,,,6.06,,,fee schedule,,,,,,,,,1012.44,,,percent of total billed charges,,,548.68,,,per diem,,,1716,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1716,,,percent of total billed charges,,,1458.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,911.37,,,percent of total billed charges,,,1716,,,percent of total billed charges,,,1716,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1157.61,,,percent of total billed charges,,,1388.59,,,percent of total billed charges,,,,,,,,,,,,,,,686.4,,,percent of total billed charges,,,,,,,,,13.54,,,fee schedule,,,9.74,,,fee schedule,,,,,,,,,1716,,,percent of total billed charges,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,,1716,,,percent of total billed charges,,,,,,,,,,,,,,,1716,,,percent of total billed charges,,,1716,,,percent of total billed charges,,,,,,,,,5.79,,,fee schedule,,,,,,,,,,,,,,,4.34,,,fee schedule,,,5.79,,,fee schedule,,,3.76,,,fee schedule,,,6.59,,,fee schedule,,,1716,,,percent of total billed charges,,,1716,,,percent of total billed charges,,,1716,,,percent of total billed charges,,,,,,,,,1203.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,858,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1011.07,,,percent of total billed charges,,
REMDESIVIR 100 MG/20 ML INJ,2500002921,CDM,636,RC,J0248,HCPCS,6195829021,NDC,9200,APC,,outpatient,facility,20,UN,1716,1716,6.1,628.06,,,,,,,,6.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.41,,,fee schedule,,,,,,,,,628.06,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,6.35,,,fee schedule,,,,,,,,,,,,,,,6.67,,,fee schedule,,,6.67,,,fee schedule,,,,,,,,,6.35,,,fee schedule,,,6.35,,,fee schedule,,,6.67,,,fee schedule,,,,,,,,,,,,,,,9.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,6.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.1,,,fee schedule,,,6.79,,,fee schedule,,,6.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.35,,,fee schedule,,,6.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,6.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,6.35,,,fee schedule,,,,,,,,,7.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,6.35,,,fee schedule,,,6.35,,,fee schedule,,,,,,,,,,,,,,,6.35,,,fee schedule,,,,,,,,,6.35,,,fee schedule,,,6.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.35,,,fee schedule,,,,,,,,,,,,,,,6.6,,,fee schedule,,,6.35,,,fee schedule,,,,,,,,,6.35,,,fee schedule,,,,,,,,,6.35,,,fee schedule,,,6.67,,,fee schedule,,,,,,,,
REMDESIVIR 100 MG/20 ML INJ,2500002921,CDM,636,RC,J0248,HCPCS,6195829021,NDC,439,EAPG,,outpatient,facility,20,UN,1716,1716,790.67,1193.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1193.91,,,fee schedule,,,790.67,,,fee schedule,,,1061.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.67,,,fee schedule,,,790.67,,,fee schedule,,,790.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,790.67,,,fee schedule,,,,,,,,,,,,,,,790.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROPIVAC/EPI/CLONIDINE/KET 50ML,2500002926,CDM,636,RC,,,,,,,,inpatient,facility,50,UN,203.61,203.61,16.29,203.61,,,,,,,,,,,,,,203.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,203.61,,,percent of total billed charges,,,,,,,,,203.61,,,percent of total billed charges,,,103.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.17,,,percent of total billed charges,,,,,,,,,,,,,,,203.61,,,percent of total billed charges,,,173.07,,,percent of total billed charges,,,,,,,,,,,,,,,203.61,,,percent of total billed charges,,,108.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,203.61,,,percent of total billed charges,,,,,,,,,,,,,,,16.29,,,percent of total billed charges,,,203.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,203.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.97,,,percent of total billed charges,,
ROPIVAC/EPI/CLONIDINE/KET 50ML,2500002926,CDM,636,RC,,,,,,,,outpatient,facility,50,UN,203.61,203.61,16.29,548.68,,144.38,,,percent of total billed charges,,,49.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,203.61,,,percent of total billed charges,,,127.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,143.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,143.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,203.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,74.52,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,203.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,203.61,,,fee schedule,,,203.61,,,percent of total billed charges,,,,,,,,,203.61,,,percent of total billed charges,,,124.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.07,,,percent of total billed charges,,,,,,,,,,,,,,,109.95,,,percent of total billed charges,,,105.88,,,percent of total billed charges,,,111.99,,,percent of total billed charges,,,,,,,,,120.13,,,percent of total billed charges,,,548.68,,,per diem,,,203.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,203.61,,,percent of total billed charges,,,173.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,108.14,,,percent of total billed charges,,,203.61,,,percent of total billed charges,,,203.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.36,,,percent of total billed charges,,,164.76,,,percent of total billed charges,,,,,,,,,,,,,,,81.44,,,percent of total billed charges,,,,,,,,,81.44,,,percent of total billed charges,,,81.44,,,percent of total billed charges,,,,,,,,,203.61,,,percent of total billed charges,,,203.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,203.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.29,,,percent of total billed charges,,,203.61,,,percent of total billed charges,,,,,,,,,,,,,,,203.61,,,percent of total billed charges,,,203.61,,,percent of total billed charges,,,,,,,,,81.44,,,percent of total billed charges,,,,,,,,,,,,,,,81.44,,,percent of total billed charges,,,81.44,,,percent of total billed charges,,,81.44,,,percent of total billed charges,,,152.71,,,percent of total billed charges,,,203.61,,,percent of total billed charges,,,203.61,,,percent of total billed charges,,,203.61,,,percent of total billed charges,,,,,,,,,142.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,119.97,,,percent of total billed charges,,
ROPIVAC/EPI/CLONIDINE/KET 50ML,2500002926,CDM,636,RC,999,EAPG,,,,,,outpatient,facility,50,UN,203.61,203.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENZOCAINE 20   SPR 57 GM,2500002927,CDM,637,RC,283091402,NDC,,,,,,inpatient,facility,57,UN,63.45,63.45,5.08,63.45,,,,,,,,,,,,,,63.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.45,,,percent of total billed charges,,,,,,,,,63.45,,,percent of total billed charges,,,32.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.07,,,percent of total billed charges,,,,,,,,,,,,,,,63.45,,,percent of total billed charges,,,53.93,,,percent of total billed charges,,,,,,,,,,,,,,,63.45,,,percent of total billed charges,,,33.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,63.45,,,percent of total billed charges,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,63.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.38,,,percent of total billed charges,,
BENZOCAINE 20   SPR 57 GM,2500002927,CDM,637,RC,283091402,NDC,,,,,,outpatient,facility,57,UN,63.45,63.45,5.08,548.68,,44.99,,,percent of total billed charges,,,15.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,63.45,,,percent of total billed charges,,,39.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,44.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,44.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,63.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,23.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,63.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,63.45,,,fee schedule,,,63.45,,,percent of total billed charges,,,,,,,,,63.45,,,percent of total billed charges,,,38.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.21,,,percent of total billed charges,,,,,,,,,,,,,,,34.26,,,percent of total billed charges,,,32.99,,,percent of total billed charges,,,34.9,,,percent of total billed charges,,,,,,,,,37.44,,,percent of total billed charges,,,548.68,,,per diem,,,63.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,63.45,,,percent of total billed charges,,,53.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.7,,,percent of total billed charges,,,63.45,,,percent of total billed charges,,,63.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.8,,,percent of total billed charges,,,51.34,,,percent of total billed charges,,,,,,,,,,,,,,,25.38,,,percent of total billed charges,,,,,,,,,23.48,,,percent of total billed charges,,,23.48,,,percent of total billed charges,,,,,,,,,63.45,,,percent of total billed charges,,,63.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,63.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.08,,,percent of total billed charges,,,63.45,,,percent of total billed charges,,,,,,,,,,,,,,,63.45,,,percent of total billed charges,,,63.45,,,percent of total billed charges,,,,,,,,,59.02,,,percent of total billed charges,,,,,,,,,,,,,,,59.02,,,percent of total billed charges,,,59.02,,,percent of total billed charges,,,59.02,,,percent of total billed charges,,,47.59,,,percent of total billed charges,,,63.45,,,percent of total billed charges,,,63.45,,,percent of total billed charges,,,63.45,,,percent of total billed charges,,,,,,,,,44.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,37.38,,,percent of total billed charges,,
BENZOCAINE 20   SPR 57 GM,2500002927,CDM,637,RC,283091402,NDC,999,EAPG,,,,outpatient,facility,57,UN,63.45,63.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMIODARONE 450 MG INJ,2500002969,CDM,636,RC,6332361609,NDC,,,,,,inpatient,facility,9,UN,18.05,18.05,1.44,18.05,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,18.05,,,percent of total billed charges,,,9.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.83,,,percent of total billed charges,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,15.34,,,percent of total billed charges,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,9.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.64,,,percent of total billed charges,,
AMIODARONE 450 MG INJ,2500002969,CDM,636,RC,6332361609,NDC,,,,,,outpatient,facility,9,UN,18.05,18.05,1.44,548.68,,12.8,,,percent of total billed charges,,,4.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,18.05,,,percent of total billed charges,,,11.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,12.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,12.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,18.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,18.05,,,fee schedule,,,18.05,,,percent of total billed charges,,,,,,,,,18.05,,,percent of total billed charges,,,11.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.86,,,percent of total billed charges,,,,,,,,,,,,,,,9.75,,,percent of total billed charges,,,9.39,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,10.65,,,percent of total billed charges,,,548.68,,,per diem,,,18.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,18.05,,,percent of total billed charges,,,15.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.59,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.18,,,percent of total billed charges,,,14.61,,,percent of total billed charges,,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,,,,,,,7.22,,,percent of total billed charges,,,7.22,,,percent of total billed charges,,,,,,,,,18.05,,,percent of total billed charges,,,18.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.44,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,7.22,,,percent of total billed charges,,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,7.22,,,percent of total billed charges,,,7.22,,,percent of total billed charges,,,13.54,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,12.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.03,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.64,,,percent of total billed charges,,
AMIODARONE 450 MG INJ,2500002969,CDM,636,RC,6332361609,NDC,999,EAPG,,,,outpatient,facility,9,UN,18.05,18.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIAZEPAM INJ 10MG,2500002972,CDM,636,RC,J3360,HCPCS,409127332,NDC,,,,inpatient,facility,2,UN,111.08,111.08,8.89,111.08,,,,,,,,,,,,,,111.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.08,,,percent of total billed charges,,,,,,,,,111.08,,,percent of total billed charges,,,56.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.65,,,percent of total billed charges,,,,,,,,,,,,,,,111.08,,,percent of total billed charges,,,94.42,,,percent of total billed charges,,,,,,,,,,,,,,,111.08,,,percent of total billed charges,,,58.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,111.08,,,percent of total billed charges,,,,,,,,,,,,,,,8.89,,,percent of total billed charges,,,111.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,111.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.45,,,percent of total billed charges,,
DIAZEPAM INJ 10MG,2500002972,CDM,636,RC,J3360,HCPCS,409127332,NDC,,,,outpatient,facility,2,UN,111.08,111.08,0.84,548.68,,78.77,,,percent of total billed charges,,,27.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,111.08,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,111.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,40.66,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.84,,,fee schedule,,,111.08,,,fee schedule,,,111.08,,,percent of total billed charges,,,,,,,,,111.08,,,percent of total billed charges,,,68.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,65.54,,,percent of total billed charges,,,548.68,,,per diem,,,111.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,111.08,,,percent of total billed charges,,,94.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.99,,,percent of total billed charges,,,111.08,,,percent of total billed charges,,,111.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.93,,,percent of total billed charges,,,89.89,,,percent of total billed charges,,,,,,,,,,,,,,,44.43,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,111.08,,,percent of total billed charges,,,111.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,111.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.89,,,percent of total billed charges,,,111.08,,,percent of total billed charges,,,,,,,,,,,,,,,111.08,,,percent of total billed charges,,,111.08,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,5.65,,,fee schedule,,,111.08,,,percent of total billed charges,,,111.08,,,percent of total billed charges,,,111.08,,,percent of total billed charges,,,,,,,,,77.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,65.45,,,percent of total billed charges,,
DIAZEPAM INJ 10MG,2500002972,CDM,636,RC,J3360,HCPCS,409127332,NDC,496,EAPG,,outpatient,facility,2,UN,111.08,111.08,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MULTITRACE NEONATAL 1 ML,2500002976,CDM,250,RC,517930225,NDC,,,,,,inpatient,facility,1,UN,19.11,19.11,1.53,19.11,,,,,,,,,,,,,,19.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.11,,,percent of total billed charges,,,,,,,,,19.11,,,percent of total billed charges,,,9.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.47,,,percent of total billed charges,,,,,,,,,,,,,,,19.11,,,percent of total billed charges,,,16.24,,,percent of total billed charges,,,,,,,,,,,,,,,19.11,,,percent of total billed charges,,,10.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,19.11,,,percent of total billed charges,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,19.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.26,,,percent of total billed charges,,
MULTITRACE NEONATAL 1 ML,2500002976,CDM,250,RC,517930225,NDC,,,,,,outpatient,facility,1,UN,19.11,19.11,1.53,548.68,,13.55,,,percent of total billed charges,,,4.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,19.11,,,percent of total billed charges,,,11.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,13.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,13.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,19.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.99,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,19.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,19.11,,,fee schedule,,,19.11,,,percent of total billed charges,,,,,,,,,19.11,,,percent of total billed charges,,,11.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,11.27,,,percent of total billed charges,,,548.68,,,per diem,,,19.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,19.11,,,percent of total billed charges,,,16.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.15,,,percent of total billed charges,,,19.11,,,percent of total billed charges,,,19.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.89,,,percent of total billed charges,,,15.46,,,percent of total billed charges,,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,,,,,,,7.64,,,percent of total billed charges,,,7.64,,,percent of total billed charges,,,,,,,,,19.11,,,percent of total billed charges,,,19.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.53,,,percent of total billed charges,,,19.11,,,percent of total billed charges,,,,,,,,,,,,,,,19.11,,,percent of total billed charges,,,19.11,,,percent of total billed charges,,,,,,,,,7.64,,,percent of total billed charges,,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,7.64,,,percent of total billed charges,,,7.64,,,percent of total billed charges,,,14.33,,,percent of total billed charges,,,19.11,,,percent of total billed charges,,,19.11,,,percent of total billed charges,,,19.11,,,percent of total billed charges,,,,,,,,,13.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.26,,,percent of total billed charges,,
MULTITRACE NEONATAL 1 ML,2500002976,CDM,250,RC,517930225,NDC,999,EAPG,,,,outpatient,facility,1,UN,19.11,19.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 1250 MG IV,2500002994,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,inpatient,facility,250,UN,79.6,79.6,6.37,79.6,,,,,,,,,,,,,,79.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.6,,,percent of total billed charges,,,,,,,,,79.6,,,percent of total billed charges,,,40.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.76,,,percent of total billed charges,,,,,,,,,,,,,,,79.6,,,percent of total billed charges,,,67.66,,,percent of total billed charges,,,,,,,,,,,,,,,79.6,,,percent of total billed charges,,,42.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,79.6,,,percent of total billed charges,,,,,,,,,,,,,,,6.37,,,percent of total billed charges,,,79.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.9,,,percent of total billed charges,,
VANCOMYCIN 1250 MG IV,2500002994,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,outpatient,facility,250,UN,79.6,79.6,2.07,548.68,,56.44,,,percent of total billed charges,,,19.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,79.6,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,79.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,29.13,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,79.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,79.6,,,fee schedule,,,79.6,,,percent of total billed charges,,,,,,,,,79.6,,,percent of total billed charges,,,48.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,46.96,,,percent of total billed charges,,,548.68,,,per diem,,,79.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,79.6,,,percent of total billed charges,,,67.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,42.28,,,percent of total billed charges,,,79.6,,,percent of total billed charges,,,79.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.7,,,percent of total billed charges,,,64.41,,,percent of total billed charges,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,79.6,,,percent of total billed charges,,,79.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,79.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.37,,,percent of total billed charges,,,79.6,,,percent of total billed charges,,,,,,,,,,,,,,,79.6,,,percent of total billed charges,,,79.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.07,,,fee schedule,,,79.6,,,percent of total billed charges,,,79.6,,,percent of total billed charges,,,79.6,,,percent of total billed charges,,,,,,,,,55.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,46.9,,,percent of total billed charges,,
VANCOMYCIN 1250 MG IV,2500002994,CDM,636,RC,J3370,HCPCS,6745734001,NDC,496,EAPG,,outpatient,facility,250,UN,79.6,79.6,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 1500 MG IV,2500002995,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,inpatient,facility,500,UN,95.5,95.5,7.64,95.5,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,,,,,,,,95.5,,,percent of total billed charges,,,48.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.3,,,percent of total billed charges,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,,50.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.27,,,percent of total billed charges,,
VANCOMYCIN 1500 MG IV,2500002995,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,outpatient,facility,500,UN,95.5,95.5,2.07,548.68,,67.72,,,percent of total billed charges,,,23.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,95.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,34.95,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,95.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,95.5,,,fee schedule,,,95.5,,,percent of total billed charges,,,,,,,,,95.5,,,percent of total billed charges,,,58.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,56.34,,,percent of total billed charges,,,548.68,,,per diem,,,95.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,95.5,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.72,,,percent of total billed charges,,,95.5,,,percent of total billed charges,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.42,,,percent of total billed charges,,,77.28,,,percent of total billed charges,,,,,,,,,,,,,,,38.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,95.5,,,percent of total billed charges,,,95.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,95.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.64,,,percent of total billed charges,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.07,,,fee schedule,,,95.5,,,percent of total billed charges,,,95.5,,,percent of total billed charges,,,95.5,,,percent of total billed charges,,,,,,,,,66.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,56.27,,,percent of total billed charges,,
VANCOMYCIN 1500 MG IV,2500002995,CDM,636,RC,J3370,HCPCS,6745734001,NDC,496,EAPG,,outpatient,facility,500,UN,95.5,95.5,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 1750 MG IV,2500002996,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,inpatient,facility,500,UN,63.53,63.53,5.08,63.53,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,,,,,,,63.53,,,percent of total billed charges,,,32.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.12,,,percent of total billed charges,,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,54,,,percent of total billed charges,,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,33.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.43,,,percent of total billed charges,,
VANCOMYCIN 1750 MG IV,2500002996,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,outpatient,facility,500,UN,63.53,63.53,2.07,548.68,,45.05,,,percent of total billed charges,,,15.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,63.53,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,23.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,63.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,63.53,,,fee schedule,,,63.53,,,percent of total billed charges,,,,,,,,,63.53,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,37.48,,,percent of total billed charges,,,548.68,,,per diem,,,63.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,63.53,,,percent of total billed charges,,,54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.74,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.86,,,percent of total billed charges,,,51.41,,,percent of total billed charges,,,,,,,,,,,,,,,25.41,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,63.53,,,percent of total billed charges,,,63.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,63.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.08,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,63.53,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.07,,,fee schedule,,,63.53,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,63.53,,,percent of total billed charges,,,,,,,,,44.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,37.43,,,percent of total billed charges,,
VANCOMYCIN 1750 MG IV,2500002996,CDM,636,RC,J3370,HCPCS,6745734001,NDC,496,EAPG,,outpatient,facility,500,UN,63.53,63.53,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 2000 MG IV,2500002997,CDM,636,RC,J3370,HCPCS,7207806699,NDC,,,,inpatient,facility,2000,UN,92.4,92.4,7.39,92.4,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,,,,,92.4,,,percent of total billed charges,,,47.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,78.54,,,percent of total billed charges,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,49.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.44,,,percent of total billed charges,,
VANCOMYCIN 2000 MG IV,2500002997,CDM,636,RC,J3370,HCPCS,7207806699,NDC,,,,outpatient,facility,2000,UN,92.4,92.4,2.07,548.68,,65.52,,,percent of total billed charges,,,22.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,92.4,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,33.82,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,92.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,92.4,,,fee schedule,,,92.4,,,percent of total billed charges,,,,,,,,,92.4,,,percent of total billed charges,,,56.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,54.52,,,percent of total billed charges,,,548.68,,,per diem,,,92.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,92.4,,,percent of total billed charges,,,78.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.07,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.33,,,percent of total billed charges,,,74.77,,,percent of total billed charges,,,,,,,,,,,,,,,36.96,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,92.4,,,percent of total billed charges,,,92.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,92.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.39,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.07,,,fee schedule,,,92.4,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,,,,,,,64.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,54.44,,,percent of total billed charges,,
VANCOMYCIN 2000 MG IV,2500002997,CDM,636,RC,J3370,HCPCS,7207806699,NDC,496,EAPG,,outpatient,facility,2000,UN,92.4,92.4,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 500 MG INJ,2500003000,CDM,636,RC,J3370,HCPCS,6745733950,NDC,,,,inpatient,facility,500,UN,31.84,31.84,2.55,31.84,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,,,,,,,31.84,,,percent of total billed charges,,,16.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.1,,,percent of total billed charges,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,27.06,,,percent of total billed charges,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,16.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.76,,,percent of total billed charges,,
VANCOMYCIN 500 MG INJ,2500003000,CDM,636,RC,J3370,HCPCS,6745733950,NDC,,,,outpatient,facility,500,UN,31.84,31.84,2.07,548.68,,22.58,,,percent of total billed charges,,,7.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,31.84,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,31.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,31.84,,,fee schedule,,,31.84,,,percent of total billed charges,,,,,,,,,31.84,,,percent of total billed charges,,,19.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,18.79,,,percent of total billed charges,,,548.68,,,per diem,,,31.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,31.84,,,percent of total billed charges,,,27.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.91,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.48,,,percent of total billed charges,,,25.76,,,percent of total billed charges,,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,31.84,,,percent of total billed charges,,,31.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.55,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.07,,,fee schedule,,,31.84,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,31.84,,,percent of total billed charges,,,,,,,,,22.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.76,,,percent of total billed charges,,
VANCOMYCIN 500 MG INJ,2500003000,CDM,636,RC,J3370,HCPCS,6745733950,NDC,496,EAPG,,outpatient,facility,500,UN,31.84,31.84,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 1 GM INJ,2500003002,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,inpatient,facility,1000,UN,63.52,63.52,5.08,63.52,,,,,,,,,,,,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.52,,,percent of total billed charges,,,,,,,,,63.52,,,percent of total billed charges,,,32.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.11,,,percent of total billed charges,,,,,,,,,,,,,,,63.52,,,percent of total billed charges,,,53.99,,,percent of total billed charges,,,,,,,,,,,,,,,63.52,,,percent of total billed charges,,,33.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.43,,,percent of total billed charges,,
VANCOMYCIN 1 GM INJ,2500003002,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,outpatient,facility,1000,UN,63.52,63.52,2.07,548.68,,45.04,,,percent of total billed charges,,,15.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,63.52,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,23.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,63.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,63.52,,,fee schedule,,,63.52,,,percent of total billed charges,,,,,,,,,63.52,,,percent of total billed charges,,,38.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,37.48,,,percent of total billed charges,,,548.68,,,per diem,,,63.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,63.52,,,percent of total billed charges,,,53.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.74,,,percent of total billed charges,,,63.52,,,percent of total billed charges,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.85,,,percent of total billed charges,,,51.4,,,percent of total billed charges,,,,,,,,,,,,,,,25.41,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,63.52,,,percent of total billed charges,,,63.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,63.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.08,,,percent of total billed charges,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,63.52,,,percent of total billed charges,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.07,,,fee schedule,,,63.52,,,percent of total billed charges,,,63.52,,,percent of total billed charges,,,63.52,,,percent of total billed charges,,,,,,,,,44.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,37.43,,,percent of total billed charges,,
VANCOMYCIN 1 GM INJ,2500003002,CDM,636,RC,J3370,HCPCS,6745734001,NDC,496,EAPG,,outpatient,facility,1000,UN,63.52,63.52,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN HCL 750 MG INJ,2500003005,CDM,636,RC,J3370,HCPCS,338358048,NDC,,,,inpatient,facility,250,UN,38.38,38.38,3.07,38.38,,,,,,,,,,,,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.38,,,percent of total billed charges,,,,,,,,,38.38,,,percent of total billed charges,,,19.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.03,,,percent of total billed charges,,,,,,,,,,,,,,,38.38,,,percent of total billed charges,,,32.62,,,percent of total billed charges,,,,,,,,,,,,,,,38.38,,,percent of total billed charges,,,20.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.61,,,percent of total billed charges,,
VANCOMYCIN HCL 750 MG INJ,2500003005,CDM,636,RC,J3370,HCPCS,338358048,NDC,,,,outpatient,facility,250,UN,38.38,38.38,2.07,548.68,,27.22,,,percent of total billed charges,,,9.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,38.38,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,14.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,38.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,38.38,,,fee schedule,,,38.38,,,percent of total billed charges,,,,,,,,,38.38,,,percent of total billed charges,,,23.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,22.64,,,percent of total billed charges,,,548.68,,,per diem,,,38.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,38.38,,,percent of total billed charges,,,32.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.38,,,percent of total billed charges,,,38.38,,,percent of total billed charges,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.89,,,percent of total billed charges,,,31.06,,,percent of total billed charges,,,,,,,,,,,,,,,15.35,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,38.38,,,percent of total billed charges,,,38.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,38.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.07,,,percent of total billed charges,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,,38.38,,,percent of total billed charges,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.07,,,fee schedule,,,38.38,,,percent of total billed charges,,,38.38,,,percent of total billed charges,,,38.38,,,percent of total billed charges,,,,,,,,,26.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,22.61,,,percent of total billed charges,,
VANCOMYCIN HCL 750 MG INJ,2500003005,CDM,636,RC,J3370,HCPCS,338358048,NDC,496,EAPG,,outpatient,facility,250,UN,38.38,38.38,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROXYZINE INJ 50 MG/ML 1 ML,2500003032,CDM,636,RC,J3410,HCPCS,517560125,NDC,,,,inpatient,facility,1,UN,101.87,101.87,8.15,101.87,,,,,,,,,,,,,,101.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.87,,,percent of total billed charges,,,,,,,,,101.87,,,percent of total billed charges,,,52.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.12,,,percent of total billed charges,,,,,,,,,,,,,,,101.87,,,percent of total billed charges,,,86.59,,,percent of total billed charges,,,,,,,,,,,,,,,101.87,,,percent of total billed charges,,,54.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,101.87,,,percent of total billed charges,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,101.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,101.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.02,,,percent of total billed charges,,
HYDROXYZINE INJ 50 MG/ML 1 ML,2500003032,CDM,636,RC,J3410,HCPCS,517560125,NDC,,,,outpatient,facility,1,UN,101.87,101.87,1.56,548.68,,72.24,,,percent of total billed charges,,,24.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,101.87,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,101.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,37.28,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.56,,,fee schedule,,,101.87,,,fee schedule,,,101.87,,,percent of total billed charges,,,,,,,,,101.87,,,percent of total billed charges,,,62.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,60.1,,,percent of total billed charges,,,548.68,,,per diem,,,101.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,101.87,,,percent of total billed charges,,,86.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.1,,,percent of total billed charges,,,101.87,,,percent of total billed charges,,,101.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.72,,,percent of total billed charges,,,82.43,,,percent of total billed charges,,,,,,,,,,,,,,,40.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,101.87,,,percent of total billed charges,,,101.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,101.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.15,,,percent of total billed charges,,,101.87,,,percent of total billed charges,,,,,,,,,,,,,,,101.87,,,percent of total billed charges,,,101.87,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,15.05,,,fee schedule,,,101.87,,,percent of total billed charges,,,101.87,,,percent of total billed charges,,,101.87,,,percent of total billed charges,,,,,,,,,71.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,60.02,,,percent of total billed charges,,
HYDROXYZINE INJ 50 MG/ML 1 ML,2500003032,CDM,636,RC,J3410,HCPCS,517560125,NDC,496,EAPG,,outpatient,facility,1,UN,101.87,101.87,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VITAMIN B12 1000 MCG/ML INJ,2500003042,CDM,636,RC,J3420,HCPCS,6968011225,NDC,,,,inpatient,facility,1,UN,10.63,10.63,0.85,10.63,,,,,,,,,,,,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.63,,,percent of total billed charges,,,,,,,,,10.63,,,percent of total billed charges,,,5.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.38,,,percent of total billed charges,,,,,,,,,,,,,,,10.63,,,percent of total billed charges,,,9.04,,,percent of total billed charges,,,,,,,,,,,,,,,10.63,,,percent of total billed charges,,,5.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,
VITAMIN B12 1000 MCG/ML INJ,2500003042,CDM,636,RC,J3420,HCPCS,6968011225,NDC,,,,outpatient,facility,1,UN,10.63,10.63,0.85,548.68,,7.54,,,percent of total billed charges,,,2.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.63,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.89,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.63,,,fee schedule,,,10.63,,,percent of total billed charges,,,,,,,,,10.63,,,percent of total billed charges,,,6.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,6.27,,,percent of total billed charges,,,548.68,,,per diem,,,10.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.63,,,percent of total billed charges,,,9.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.65,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.17,,,percent of total billed charges,,,8.6,,,percent of total billed charges,,,,,,,,,,,,,,,4.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10.63,,,percent of total billed charges,,,10.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.85,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,10.63,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.16,,,fee schedule,,,10.63,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,,,,,,,7.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.26,,,percent of total billed charges,,
VITAMIN B12 1000 MCG/ML INJ,2500003042,CDM,636,RC,J3420,HCPCS,6968011225,NDC,999,EAPG,,outpatient,facility,1,UN,10.63,10.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHACHOLINE CHLORIDE,2500003049,CDM,250,RC,6428111006,NDC,,,,,,inpatient,facility,18,UN,534.6,534.6,42.77,534.6,,,,,,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,272.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,455.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,320.76,,,percent of total billed charges,,,,,,,,,,,,,,,534.6,,,percent of total billed charges,,,454.41,,,percent of total billed charges,,,,,,,,,,,,,,,534.6,,,percent of total billed charges,,,283.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,,,,,,,42.77,,,percent of total billed charges,,,534.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,314.99,,,percent of total billed charges,,
METHACHOLINE CHLORIDE,2500003049,CDM,250,RC,6428111006,NDC,,,,,,outpatient,facility,18,UN,534.6,534.6,42.77,548.68,,379.08,,,percent of total billed charges,,,130.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,534.6,,,percent of total billed charges,,,335.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,375.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,375.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,195.66,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,534.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,534.6,,,fee schedule,,,534.6,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,327.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,380.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,315.41,,,percent of total billed charges,,,548.68,,,per diem,,,534.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,534.6,,,percent of total billed charges,,,454.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,283.93,,,percent of total billed charges,,,534.6,,,percent of total billed charges,,,534.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.64,,,percent of total billed charges,,,432.6,,,percent of total billed charges,,,,,,,,,,,,,,,213.84,,,percent of total billed charges,,,,,,,,,213.84,,,percent of total billed charges,,,213.84,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,534.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,534.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,42.77,,,percent of total billed charges,,,534.6,,,percent of total billed charges,,,,,,,,,,,,,,,534.6,,,percent of total billed charges,,,534.6,,,percent of total billed charges,,,,,,,,,213.84,,,percent of total billed charges,,,,,,,,,,,,,,,213.84,,,percent of total billed charges,,,213.84,,,percent of total billed charges,,,213.84,,,percent of total billed charges,,,400.95,,,percent of total billed charges,,,534.6,,,percent of total billed charges,,,534.6,,,percent of total billed charges,,,534.6,,,percent of total billed charges,,,,,,,,,374.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,314.99,,,percent of total billed charges,,
METHACHOLINE CHLORIDE,2500003049,CDM,250,RC,6428111006,NDC,999,EAPG,,,,outpatient,facility,18,UN,534.6,534.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VITAMIN K PHYTONADIONE 10MG IN,2500003052,CDM,636,RC,J3430,HCPCS,4359840516,NDC,,,,inpatient,facility,1,UN,141.14,141.14,11.29,141.14,,,,,,,,,,,,,,141.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.14,,,percent of total billed charges,,,,,,,,,141.14,,,percent of total billed charges,,,72.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.68,,,percent of total billed charges,,,,,,,,,,,,,,,141.14,,,percent of total billed charges,,,119.97,,,percent of total billed charges,,,,,,,,,,,,,,,141.14,,,percent of total billed charges,,,74.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,141.14,,,percent of total billed charges,,,,,,,,,,,,,,,11.29,,,percent of total billed charges,,,141.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,141.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.16,,,percent of total billed charges,,
VITAMIN K PHYTONADIONE 10MG IN,2500003052,CDM,636,RC,J3430,HCPCS,4359840516,NDC,,,,outpatient,facility,1,UN,141.14,141.14,1.63,548.68,,100.08,,,percent of total billed charges,,,34.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,141.14,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,141.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,51.66,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.63,,,fee schedule,,,141.14,,,fee schedule,,,141.14,,,percent of total billed charges,,,,,,,,,141.14,,,percent of total billed charges,,,86.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,83.27,,,percent of total billed charges,,,548.68,,,per diem,,,141.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,141.14,,,percent of total billed charges,,,119.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.96,,,percent of total billed charges,,,141.14,,,percent of total billed charges,,,141.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.21,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,,,,,,,,,,,,,56.46,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,141.14,,,percent of total billed charges,,,141.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,141.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.29,,,percent of total billed charges,,,141.14,,,percent of total billed charges,,,,,,,,,,,,,,,141.14,,,percent of total billed charges,,,141.14,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.96,,,fee schedule,,,141.14,,,percent of total billed charges,,,141.14,,,percent of total billed charges,,,141.14,,,percent of total billed charges,,,,,,,,,98.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,83.16,,,percent of total billed charges,,
VITAMIN K PHYTONADIONE 10MG IN,2500003052,CDM,636,RC,J3430,HCPCS,4359840516,NDC,435,EAPG,,outpatient,facility,1,UN,141.14,141.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYALURONIDASE INJ UP TO 150 U,2500003070,CDM,636,RC,J3470,HCPCS,1865711704,NDC,,,,inpatient,facility,1,UN,184.14,184.14,14.73,184.14,,,,,,,,,,,,,,184.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.14,,,percent of total billed charges,,,,,,,,,184.14,,,percent of total billed charges,,,94.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.48,,,percent of total billed charges,,,,,,,,,,,,,,,184.14,,,percent of total billed charges,,,156.52,,,percent of total billed charges,,,,,,,,,,,,,,,184.14,,,percent of total billed charges,,,97.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,184.14,,,percent of total billed charges,,,,,,,,,,,,,,,14.73,,,percent of total billed charges,,,184.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,184.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.5,,,percent of total billed charges,,
HYALURONIDASE INJ UP TO 150 U,2500003070,CDM,636,RC,J3470,HCPCS,1865711704,NDC,,,,outpatient,facility,1,UN,184.14,184.14,14.73,548.68,,130.57,,,percent of total billed charges,,,44.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,184.14,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,184.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,67.4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,184.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,184.14,,,fee schedule,,,184.14,,,percent of total billed charges,,,,,,,,,184.14,,,percent of total billed charges,,,112.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,108.64,,,percent of total billed charges,,,548.68,,,per diem,,,184.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,184.14,,,percent of total billed charges,,,156.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,97.8,,,percent of total billed charges,,,184.14,,,percent of total billed charges,,,184.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.22,,,percent of total billed charges,,,149.01,,,percent of total billed charges,,,,,,,,,,,,,,,73.66,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,184.14,,,percent of total billed charges,,,184.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,184.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.73,,,percent of total billed charges,,,184.14,,,percent of total billed charges,,,,,,,,,,,,,,,184.14,,,percent of total billed charges,,,184.14,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,30.22,,,fee schedule,,,184.14,,,percent of total billed charges,,,184.14,,,percent of total billed charges,,,184.14,,,percent of total billed charges,,,,,,,,,129.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,108.5,,,percent of total billed charges,,
HYALURONIDASE INJ UP TO 150 U,2500003070,CDM,636,RC,J3470,HCPCS,1865711704,NDC,436,EAPG,,outpatient,facility,1,UN,184.14,184.14,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYALURONIDASE INJ 200 UNITS,2500003071,CDM,636,RC,J3471,HCPCS,2420800202,NDC,,,,inpatient,facility,1.2,UN,398.74,398.74,31.9,398.74,,,,,,,,,,,,,,398.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.74,,,percent of total billed charges,,,,,,,,,398.74,,,percent of total billed charges,,,203.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.24,,,percent of total billed charges,,,,,,,,,,,,,,,398.74,,,percent of total billed charges,,,338.93,,,percent of total billed charges,,,,,,,,,,,,,,,398.74,,,percent of total billed charges,,,211.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,398.74,,,percent of total billed charges,,,,,,,,,,,,,,,31.9,,,percent of total billed charges,,,398.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,398.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.94,,,percent of total billed charges,,
HYALURONIDASE INJ 200 UNITS,2500003071,CDM,636,RC,J3471,HCPCS,2420800202,NDC,,,,outpatient,facility,1.2,UN,398.74,398.74,0.52,548.68,,282.75,,,percent of total billed charges,,,97.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,398.74,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,398.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,145.94,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,398.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,398.74,,,fee schedule,,,398.74,,,percent of total billed charges,,,,,,,,,398.74,,,percent of total billed charges,,,244.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,235.26,,,percent of total billed charges,,,548.68,,,per diem,,,398.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,398.74,,,percent of total billed charges,,,338.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,211.77,,,percent of total billed charges,,,398.74,,,percent of total billed charges,,,398.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,268.99,,,percent of total billed charges,,,322.66,,,percent of total billed charges,,,,,,,,,,,,,,,159.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,398.74,,,percent of total billed charges,,,398.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,398.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.9,,,percent of total billed charges,,,398.74,,,percent of total billed charges,,,,,,,,,,,,,,,398.74,,,percent of total billed charges,,,398.74,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.52,,,fee schedule,,,398.74,,,percent of total billed charges,,,398.74,,,percent of total billed charges,,,398.74,,,percent of total billed charges,,,,,,,,,279.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.37,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,234.94,,,percent of total billed charges,,
HYALURONIDASE INJ 200 UNITS,2500003071,CDM,636,RC,J3471,HCPCS,2420800202,NDC,436,EAPG,,outpatient,facility,1.2,UN,398.74,398.74,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAGNESIUM SULF INJ 1 GM (8MEQ),2500003081,CDM,636,RC,J3475,HCPCS,6332306403,NDC,,,,inpatient,facility,2,UN,7.49,7.49,0.6,7.49,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,7.49,,,percent of total billed charges,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.49,,,percent of total billed charges,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,6.37,,,percent of total billed charges,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.41,,,percent of total billed charges,,
MAGNESIUM SULF INJ 1 GM (8MEQ),2500003081,CDM,636,RC,J3475,HCPCS,6332306403,NDC,,,,outpatient,facility,2,UN,7.49,7.49,0.52,548.68,,5.31,,,percent of total billed charges,,,1.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.49,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.49,,,fee schedule,,,7.49,,,percent of total billed charges,,,,,,,,,7.49,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,4.42,,,percent of total billed charges,,,548.68,,,per diem,,,7.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.49,,,percent of total billed charges,,,6.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.98,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.05,,,percent of total billed charges,,,6.06,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7.49,,,percent of total billed charges,,,7.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.6,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.52,,,fee schedule,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,5.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.41,,,percent of total billed charges,,
MAGNESIUM SULF INJ 1 GM (8MEQ),2500003081,CDM,636,RC,J3475,HCPCS,6332306403,NDC,496,EAPG,,outpatient,facility,2,UN,7.49,7.49,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAGNESIUM SULF INJ 50  10ML,2500003082,CDM,636,RC,J3475,HCPCS,6332306411,NDC,,,,inpatient,facility,10,UN,7.16,7.16,0.57,7.16,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,7.16,,,percent of total billed charges,,,3.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,6.09,,,percent of total billed charges,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,
MAGNESIUM SULF INJ 50  10ML,2500003082,CDM,636,RC,J3475,HCPCS,6332306411,NDC,,,,outpatient,facility,10,UN,7.16,7.16,0.52,548.68,,5.08,,,percent of total billed charges,,,1.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.16,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.62,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.16,,,fee schedule,,,7.16,,,percent of total billed charges,,,,,,,,,7.16,,,percent of total billed charges,,,4.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,4.22,,,percent of total billed charges,,,548.68,,,per diem,,,7.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.16,,,percent of total billed charges,,,6.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.83,,,percent of total billed charges,,,5.79,,,percent of total billed charges,,,,,,,,,,,,,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7.16,,,percent of total billed charges,,,7.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.57,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.52,,,fee schedule,,,7.16,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.22,,,percent of total billed charges,,
MAGNESIUM SULF INJ 50  10ML,2500003082,CDM,636,RC,J3475,HCPCS,6332306411,NDC,496,EAPG,,outpatient,facility,10,UN,7.16,7.16,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAGNESIUM SULF IV 1 GM/100 ML,2500003083,CDM,636,RC,J3475,HCPCS,338170940,NDC,,,,inpatient,facility,100,UN,21.08,21.08,1.69,21.08,,,,,,,,,,,,,,21.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.08,,,percent of total billed charges,,,,,,,,,21.08,,,percent of total billed charges,,,10.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.65,,,percent of total billed charges,,,,,,,,,,,,,,,21.08,,,percent of total billed charges,,,17.92,,,percent of total billed charges,,,,,,,,,,,,,,,21.08,,,percent of total billed charges,,,11.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,21.08,,,percent of total billed charges,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,21.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.42,,,percent of total billed charges,,
MAGNESIUM SULF IV 1 GM/100 ML,2500003083,CDM,636,RC,J3475,HCPCS,338170940,NDC,,,,outpatient,facility,100,UN,21.08,21.08,0.52,548.68,,14.95,,,percent of total billed charges,,,5.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,21.08,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,21.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.72,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,21.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,21.08,,,fee schedule,,,21.08,,,percent of total billed charges,,,,,,,,,21.08,,,percent of total billed charges,,,12.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,12.44,,,percent of total billed charges,,,548.68,,,per diem,,,21.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,21.08,,,percent of total billed charges,,,17.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.2,,,percent of total billed charges,,,21.08,,,percent of total billed charges,,,21.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,17.06,,,percent of total billed charges,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,21.08,,,percent of total billed charges,,,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.69,,,percent of total billed charges,,,21.08,,,percent of total billed charges,,,,,,,,,,,,,,,21.08,,,percent of total billed charges,,,21.08,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.52,,,fee schedule,,,21.08,,,percent of total billed charges,,,21.08,,,percent of total billed charges,,,21.08,,,percent of total billed charges,,,,,,,,,14.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,12.42,,,percent of total billed charges,,
MAGNESIUM SULF IV 1 GM/100 ML,2500003083,CDM,636,RC,J3475,HCPCS,338170940,NDC,496,EAPG,,outpatient,facility,100,UN,21.08,21.08,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAGNESIUM SULF IV 4 GM/100 ML,2500003085,CDM,636,RC,J3475,HCPCS,409672923,NDC,,,,inpatient,facility,100,UN,26.5,26.5,2.12,26.5,,,,,,,,,,,,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.5,,,percent of total billed charges,,,,,,,,,26.5,,,percent of total billed charges,,,13.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.9,,,percent of total billed charges,,,,,,,,,,,,,,,26.5,,,percent of total billed charges,,,22.52,,,percent of total billed charges,,,,,,,,,,,,,,,26.5,,,percent of total billed charges,,,14.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,
MAGNESIUM SULF IV 4 GM/100 ML,2500003085,CDM,636,RC,J3475,HCPCS,409672923,NDC,,,,outpatient,facility,100,UN,26.5,26.5,0.52,548.68,,18.79,,,percent of total billed charges,,,6.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,26.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.7,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,26.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,26.5,,,fee schedule,,,26.5,,,percent of total billed charges,,,,,,,,,26.5,,,percent of total billed charges,,,16.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,15.64,,,percent of total billed charges,,,548.68,,,per diem,,,26.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,26.5,,,percent of total billed charges,,,22.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.07,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.88,,,percent of total billed charges,,,21.44,,,percent of total billed charges,,,,,,,,,,,,,,,10.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,26.5,,,percent of total billed charges,,,26.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.12,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,26.5,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.52,,,fee schedule,,,26.5,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,,,,,,,18.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15.61,,,percent of total billed charges,,
MAGNESIUM SULF IV 4 GM/100 ML,2500003085,CDM,636,RC,J3475,HCPCS,409672923,NDC,496,EAPG,,outpatient,facility,100,UN,26.5,26.5,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM CL INJ 10 MEQ,2500003090,CDM,636,RC,J3480,HCPCS,6332396505,NDC,,,,inpatient,facility,5,ML,9.5,9.5,0.76,9.5,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,9.5,,,percent of total billed charges,,,4.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,8.07,,,percent of total billed charges,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,5.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.6,,,percent of total billed charges,,
POTASSIUM CL INJ 10 MEQ,2500003090,CDM,636,RC,J3480,HCPCS,6332396505,NDC,,,,outpatient,facility,5,ML,9.5,9.5,0.11,548.68,,6.74,,,percent of total billed charges,,,2.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.48,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.5,,,fee schedule,,,9.5,,,percent of total billed charges,,,,,,,,,9.5,,,percent of total billed charges,,,5.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,5.6,,,percent of total billed charges,,,548.68,,,per diem,,,9.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.5,,,percent of total billed charges,,,8.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.05,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.41,,,percent of total billed charges,,,7.69,,,percent of total billed charges,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9.5,,,percent of total billed charges,,,9.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.76,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,9.5,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,6.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.6,,,percent of total billed charges,,
POTASSIUM CL INJ 10 MEQ,2500003090,CDM,636,RC,J3480,HCPCS,6332396505,NDC,999,EAPG,,outpatient,facility,5,ML,9.5,9.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM CL INJ 20 MEQ,2500003092,CDM,636,RC,J3480,HCPCS,6332396510,NDC,,,,inpatient,facility,10,UN,6.63,6.63,0.53,6.63,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,,,,,,,6.63,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.91,,,percent of total billed charges,,
POTASSIUM CL INJ 20 MEQ,2500003092,CDM,636,RC,J3480,HCPCS,6332396510,NDC,,,,outpatient,facility,10,UN,6.63,6.63,0.11,548.68,,4.7,,,percent of total billed charges,,,1.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.63,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.43,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.63,,,fee schedule,,,6.63,,,percent of total billed charges,,,,,,,,,6.63,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,3.91,,,percent of total billed charges,,,548.68,,,per diem,,,6.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.63,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.47,,,percent of total billed charges,,,5.36,,,percent of total billed charges,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6.63,,,percent of total billed charges,,,6.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.53,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,6.63,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,,,,,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.91,,,percent of total billed charges,,
POTASSIUM CL INJ 20 MEQ,2500003092,CDM,636,RC,J3480,HCPCS,6332396510,NDC,999,EAPG,,outpatient,facility,10,UN,6.63,6.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM CL INJ 40 MEQ,2500003094,CDM,636,RC,J3480,HCPCS,6332396520,NDC,,,,inpatient,facility,20,UN,7.59,7.59,0.61,7.59,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,7.59,,,percent of total billed charges,,,3.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,6.45,,,percent of total billed charges,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.47,,,percent of total billed charges,,
POTASSIUM CL INJ 40 MEQ,2500003094,CDM,636,RC,J3480,HCPCS,6332396520,NDC,,,,outpatient,facility,20,UN,7.59,7.59,0.11,548.68,,5.38,,,percent of total billed charges,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.59,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.78,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.59,,,fee schedule,,,7.59,,,percent of total billed charges,,,,,,,,,7.59,,,percent of total billed charges,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,4.48,,,percent of total billed charges,,,548.68,,,per diem,,,7.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.59,,,percent of total billed charges,,,6.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7.59,,,percent of total billed charges,,,7.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.61,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,7.59,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,5.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.79,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.47,,,percent of total billed charges,,
POTASSIUM CL INJ 40 MEQ,2500003094,CDM,636,RC,J3480,HCPCS,6332396520,NDC,999,EAPG,,outpatient,facility,20,UN,7.59,7.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BARICITINIB 2 MG TABLET,2500003099,CDM,637,RC,2418230,NDC,,,,,,inpatient,facility,2,UN,288.42,288.42,23.07,288.42,,,,,,,,,,,,,,288.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288.42,,,percent of total billed charges,,,,,,,,,288.42,,,percent of total billed charges,,,147.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.05,,,percent of total billed charges,,,,,,,,,,,,,,,288.42,,,percent of total billed charges,,,245.16,,,percent of total billed charges,,,,,,,,,,,,,,,288.42,,,percent of total billed charges,,,153.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,288.42,,,percent of total billed charges,,,,,,,,,,,,,,,23.07,,,percent of total billed charges,,,288.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.94,,,percent of total billed charges,,
BARICITINIB 2 MG TABLET,2500003099,CDM,637,RC,2418230,NDC,,,,,,outpatient,facility,2,UN,288.42,288.42,23.07,548.68,,204.52,,,percent of total billed charges,,,70.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,288.42,,,percent of total billed charges,,,180.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,202.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,202.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,288.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,105.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,288.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,288.42,,,fee schedule,,,288.42,,,percent of total billed charges,,,,,,,,,288.42,,,percent of total billed charges,,,176.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.5,,,percent of total billed charges,,,,,,,,,,,,,,,155.75,,,percent of total billed charges,,,149.98,,,percent of total billed charges,,,158.63,,,percent of total billed charges,,,,,,,,,170.17,,,percent of total billed charges,,,548.68,,,per diem,,,288.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,288.42,,,percent of total billed charges,,,245.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,153.18,,,percent of total billed charges,,,288.42,,,percent of total billed charges,,,288.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.57,,,percent of total billed charges,,,233.39,,,percent of total billed charges,,,,,,,,,,,,,,,115.37,,,percent of total billed charges,,,,,,,,,106.72,,,percent of total billed charges,,,106.72,,,percent of total billed charges,,,,,,,,,288.42,,,percent of total billed charges,,,288.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,288.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.07,,,percent of total billed charges,,,288.42,,,percent of total billed charges,,,,,,,,,,,,,,,288.42,,,percent of total billed charges,,,288.42,,,percent of total billed charges,,,,,,,,,268.29,,,percent of total billed charges,,,,,,,,,,,,,,,268.29,,,percent of total billed charges,,,268.29,,,percent of total billed charges,,,268.29,,,percent of total billed charges,,,216.31,,,percent of total billed charges,,,288.42,,,percent of total billed charges,,,288.42,,,percent of total billed charges,,,288.42,,,percent of total billed charges,,,,,,,,,202.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,169.94,,,percent of total billed charges,,
BARICITINIB 2 MG TABLET,2500003099,CDM,637,RC,2418230,NDC,999,EAPG,,,,outpatient,facility,2,UN,288.42,288.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLYCOPYRROLATE/FORM 10.7GM INH,2500003109,CDM,637,RC,310460012,NDC,,,,,,inpatient,facility,10.7,UN,1564.63,1564.63,125.17,1564.63,,,,,,,,,,,,,,1564.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1564.63,,,percent of total billed charges,,,,,,,,,1564.63,,,percent of total billed charges,,,798.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1332.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,938.78,,,percent of total billed charges,,,,,,,,,,,,,,,1564.63,,,percent of total billed charges,,,1329.94,,,percent of total billed charges,,,,,,,,,,,,,,,1564.63,,,percent of total billed charges,,,830.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,625.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1564.63,,,percent of total billed charges,,,,,,,,,,,,,,,125.17,,,percent of total billed charges,,,1564.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1564.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,921.88,,,percent of total billed charges,,
GLYCOPYRROLATE/FORM 10.7GM INH,2500003109,CDM,637,RC,310460012,NDC,,,,,,outpatient,facility,10.7,UN,1564.63,1564.63,125.17,1564.63,,1109.48,,,percent of total billed charges,,,381.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1564.63,,,percent of total billed charges,,,980.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1099.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1099.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1564.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,572.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1564.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1564.63,,,fee schedule,,,1564.63,,,percent of total billed charges,,,,,,,,,1564.63,,,percent of total billed charges,,,958.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.8,,,percent of total billed charges,,,,,,,,,,,,,,,844.9,,,percent of total billed charges,,,813.61,,,percent of total billed charges,,,860.55,,,percent of total billed charges,,,,,,,,,923.13,,,percent of total billed charges,,,548.68,,,per diem,,,1564.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1564.63,,,percent of total billed charges,,,1329.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,830.97,,,percent of total billed charges,,,1564.63,,,percent of total billed charges,,,1564.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1055.5,,,percent of total billed charges,,,1266.1,,,percent of total billed charges,,,,,,,,,,,,,,,625.85,,,percent of total billed charges,,,,,,,,,578.91,,,percent of total billed charges,,,578.91,,,percent of total billed charges,,,,,,,,,1564.63,,,percent of total billed charges,,,1564.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1564.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,125.17,,,percent of total billed charges,,,1564.63,,,percent of total billed charges,,,,,,,,,,,,,,,1564.63,,,percent of total billed charges,,,1564.63,,,percent of total billed charges,,,,,,,,,1455.42,,,percent of total billed charges,,,,,,,,,,,,,,,1455.42,,,percent of total billed charges,,,1455.42,,,percent of total billed charges,,,1455.42,,,percent of total billed charges,,,1173.47,,,percent of total billed charges,,,1564.63,,,percent of total billed charges,,,1564.63,,,percent of total billed charges,,,1564.63,,,percent of total billed charges,,,,,,,,,1096.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,782.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,921.88,,,percent of total billed charges,,
GLYCOPYRROLATE/FORM 10.7GM INH,2500003109,CDM,637,RC,310460012,NDC,999,EAPG,,,,outpatient,facility,10.7,UN,1564.63,1564.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REVEFENACIN 175 MCG/3 ML NEB,2500003111,CDM,637,RC,4950280693,NDC,,,,,,inpatient,facility,3,UN,165.17,165.17,13.21,165.17,,,,,,,,,,,,,,165.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.17,,,percent of total billed charges,,,,,,,,,165.17,,,percent of total billed charges,,,84.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.1,,,percent of total billed charges,,,,,,,,,,,,,,,165.17,,,percent of total billed charges,,,140.39,,,percent of total billed charges,,,,,,,,,,,,,,,165.17,,,percent of total billed charges,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,165.17,,,percent of total billed charges,,,,,,,,,,,,,,,13.21,,,percent of total billed charges,,,165.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.32,,,percent of total billed charges,,
REVEFENACIN 175 MCG/3 ML NEB,2500003111,CDM,637,RC,4950280693,NDC,,,,,,outpatient,facility,3,UN,165.17,165.17,13.21,548.68,,117.12,,,percent of total billed charges,,,40.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,165.17,,,percent of total billed charges,,,103.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,116.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,116.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,165.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,60.45,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,165.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,165.17,,,fee schedule,,,165.17,,,percent of total billed charges,,,,,,,,,165.17,,,percent of total billed charges,,,101.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.68,,,percent of total billed charges,,,,,,,,,,,,,,,89.19,,,percent of total billed charges,,,85.89,,,percent of total billed charges,,,90.84,,,percent of total billed charges,,,,,,,,,97.45,,,percent of total billed charges,,,548.68,,,per diem,,,165.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,165.17,,,percent of total billed charges,,,140.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,165.17,,,percent of total billed charges,,,165.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.42,,,percent of total billed charges,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,66.07,,,percent of total billed charges,,,,,,,,,61.11,,,percent of total billed charges,,,61.11,,,percent of total billed charges,,,,,,,,,165.17,,,percent of total billed charges,,,165.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,165.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.21,,,percent of total billed charges,,,165.17,,,percent of total billed charges,,,,,,,,,,,,,,,165.17,,,percent of total billed charges,,,165.17,,,percent of total billed charges,,,,,,,,,153.64,,,percent of total billed charges,,,,,,,,,,,,,,,153.64,,,percent of total billed charges,,,153.64,,,percent of total billed charges,,,153.64,,,percent of total billed charges,,,123.88,,,percent of total billed charges,,,165.17,,,percent of total billed charges,,,165.17,,,percent of total billed charges,,,165.17,,,percent of total billed charges,,,,,,,,,115.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,97.32,,,percent of total billed charges,,
REVEFENACIN 175 MCG/3 ML NEB,2500003111,CDM,637,RC,4950280693,NDC,999,EAPG,,,,outpatient,facility,3,UN,165.17,165.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ISATUXIMAB-IRFC 100 MG INJ,2500003126,CDM,636,RC,J9227,HCPCS,24065401,NDC,,,,inpatient,facility,5,UN,2548.22,2548.22,203.86,2548.22,,,,,,,,,,,,,,2548.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2548.22,,,percent of total billed charges,,,,,,,,,2548.22,,,percent of total billed charges,,,1301.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2170.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1528.93,,,percent of total billed charges,,,,,,,,,,,,,,,2548.22,,,percent of total billed charges,,,2165.99,,,percent of total billed charges,,,,,,,,,,,,,,,2548.22,,,percent of total billed charges,,,1353.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1019.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2548.22,,,percent of total billed charges,,,,,,,,,,,,,,,203.86,,,percent of total billed charges,,,2548.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2548.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1501.41,,,percent of total billed charges,,
ISATUXIMAB-IRFC 100 MG INJ,2500003126,CDM,636,RC,J9227,HCPCS,24065401,NDC,,,,outpatient,facility,5,UN,2548.22,2548.22,48.08,2548.22,,76.42,,,fee schedule,,,,,,,,,2548.22,,,percent of total billed charges,,,101.23,,,fee schedule,,,95.77,,,fee schedule,,,,,,,,,95.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2548.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2548.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2548.22,,,fee schedule,,,2548.22,,,percent of total billed charges,,,,,,,,,2548.22,,,percent of total billed charges,,,1561.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1815.61,,,percent of total billed charges,,,,,,,,,,,,,,,76.5,,,fee schedule,,,76.5,,,fee schedule,,,76.5,,,fee schedule,,,,,,,,,1503.45,,,percent of total billed charges,,,548.68,,,per diem,,,2548.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2548.22,,,percent of total billed charges,,,2165.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1353.36,,,percent of total billed charges,,,2548.22,,,percent of total billed charges,,,2548.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1719.03,,,percent of total billed charges,,,2062.02,,,percent of total billed charges,,,,,,,,,,,,,,,1019.29,,,percent of total billed charges,,,,,,,,,173.1,,,fee schedule,,,124.56,,,fee schedule,,,,,,,,,2548.22,,,percent of total billed charges,,,,,,,,,,,,,,,203.86,,,percent of total billed charges,,,2548.22,,,percent of total billed charges,,,,,,,,,,,,,,,2548.22,,,percent of total billed charges,,,2548.22,,,percent of total billed charges,,,,,,,,,73.97,,,fee schedule,,,,,,,,,,,,,,,64.11,,,fee schedule,,,85.48,,,fee schedule,,,48.08,,,fee schedule,,,80.94,,,fee schedule,,,2548.22,,,percent of total billed charges,,,2548.22,,,percent of total billed charges,,,2548.22,,,percent of total billed charges,,,,,,,,,1786.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1274.11,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1501.41,,,percent of total billed charges,,
ISATUXIMAB-IRFC 100 MG INJ,2500003126,CDM,636,RC,J9227,HCPCS,24065401,NDC,9377,APC,,outpatient,facility,5,UN,2548.22,2548.22,76.18,932.65,,,,,,,,81.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,79.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.14,,,fee schedule,,,,,,,,,932.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,79.35,,,fee schedule,,,,,,,,,,,,,,,83.32,,,fee schedule,,,83.32,,,fee schedule,,,,,,,,,79.35,,,fee schedule,,,79.35,,,fee schedule,,,83.32,,,fee schedule,,,,,,,,,,,,,,,119.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,79.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.18,,,fee schedule,,,84.9,,,fee schedule,,,83.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.35,,,fee schedule,,,79.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,82.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,79.35,,,fee schedule,,,,,,,,,99.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,99.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,79.35,,,fee schedule,,,79.35,,,fee schedule,,,,,,,,,,,,,,,79.35,,,fee schedule,,,,,,,,,79.35,,,fee schedule,,,81.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.35,,,fee schedule,,,,,,,,,,,,,,,82.52,,,fee schedule,,,79.35,,,fee schedule,,,,,,,,,79.35,,,fee schedule,,,,,,,,,79.35,,,fee schedule,,,83.32,,,fee schedule,,,,,,,,
ISATUXIMAB-IRFC 100 MG INJ,2500003126,CDM,636,RC,J9227,HCPCS,24065401,NDC,462,EAPG,,outpatient,facility,5,UN,2548.22,2548.22,4530.01,6840.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6840.32,,,fee schedule,,,4530.01,,,fee schedule,,,6081.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMINO 8 /D14W 2000 ML,2500003136,CDM,258,RC,338018401,NDC,,,,,,inpatient,facility,2000,UN,270.63,270.63,21.65,270.63,,,,,,,,,,,,,,270.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270.63,,,percent of total billed charges,,,,,,,,,270.63,,,percent of total billed charges,,,138.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.38,,,percent of total billed charges,,,,,,,,,,,,,,,270.63,,,percent of total billed charges,,,230.04,,,percent of total billed charges,,,,,,,,,,,,,,,270.63,,,percent of total billed charges,,,143.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,270.63,,,percent of total billed charges,,,,,,,,,,,,,,,21.65,,,percent of total billed charges,,,270.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,270.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.46,,,percent of total billed charges,,
AMINO 8 /D14W 2000 ML,2500003136,CDM,258,RC,338018401,NDC,,,,,,outpatient,facility,2000,UN,270.63,270.63,21.65,548.68,,191.9,,,percent of total billed charges,,,66.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,270.63,,,percent of total billed charges,,,169.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,190.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,190.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,270.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,99.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,270.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,270.63,,,fee schedule,,,270.63,,,percent of total billed charges,,,,,,,,,270.63,,,percent of total billed charges,,,165.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,159.67,,,percent of total billed charges,,,548.68,,,per diem,,,270.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,270.63,,,percent of total billed charges,,,230.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,143.73,,,percent of total billed charges,,,270.63,,,percent of total billed charges,,,270.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.57,,,percent of total billed charges,,,218.99,,,percent of total billed charges,,,,,,,,,,,,,,,108.25,,,percent of total billed charges,,,,,,,,,108.25,,,percent of total billed charges,,,108.25,,,percent of total billed charges,,,,,,,,,270.63,,,percent of total billed charges,,,270.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,270.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.65,,,percent of total billed charges,,,270.63,,,percent of total billed charges,,,,,,,,,,,,,,,270.63,,,percent of total billed charges,,,270.63,,,percent of total billed charges,,,,,,,,,108.25,,,percent of total billed charges,,,,,,,,,,,,,,,108.25,,,percent of total billed charges,,,108.25,,,percent of total billed charges,,,108.25,,,percent of total billed charges,,,202.97,,,percent of total billed charges,,,270.63,,,percent of total billed charges,,,270.63,,,percent of total billed charges,,,270.63,,,percent of total billed charges,,,,,,,,,189.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,159.46,,,percent of total billed charges,,
AMINO 8 /D14W 2000 ML,2500003136,CDM,258,RC,338018401,NDC,999,EAPG,,,,outpatient,facility,2000,UN,270.63,270.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMINO 8 /D14W 2000 ML LYTE,2500003138,CDM,258,RC,338020604,NDC,,,,,,inpatient,facility,2000,UN,399.04,399.04,31.92,399.04,,,,,,,,,,,,,,399.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,399.04,,,percent of total billed charges,,,,,,,,,399.04,,,percent of total billed charges,,,203.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.42,,,percent of total billed charges,,,,,,,,,,,,,,,399.04,,,percent of total billed charges,,,339.18,,,percent of total billed charges,,,,,,,,,,,,,,,399.04,,,percent of total billed charges,,,211.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,399.04,,,percent of total billed charges,,,,,,,,,,,,,,,31.92,,,percent of total billed charges,,,399.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,399.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.11,,,percent of total billed charges,,
AMINO 8 /D14W 2000 ML LYTE,2500003138,CDM,258,RC,338020604,NDC,,,,,,outpatient,facility,2000,UN,399.04,399.04,31.92,548.68,,282.96,,,percent of total billed charges,,,97.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,399.04,,,percent of total billed charges,,,250.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,280.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,280.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,399.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,146.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,399.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,399.04,,,fee schedule,,,399.04,,,percent of total billed charges,,,,,,,,,399.04,,,percent of total billed charges,,,244.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,235.43,,,percent of total billed charges,,,548.68,,,per diem,,,399.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,399.04,,,percent of total billed charges,,,339.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,211.93,,,percent of total billed charges,,,399.04,,,percent of total billed charges,,,399.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,269.19,,,percent of total billed charges,,,322.9,,,percent of total billed charges,,,,,,,,,,,,,,,159.62,,,percent of total billed charges,,,,,,,,,159.62,,,percent of total billed charges,,,159.62,,,percent of total billed charges,,,,,,,,,399.04,,,percent of total billed charges,,,399.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,399.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.92,,,percent of total billed charges,,,399.04,,,percent of total billed charges,,,,,,,,,,,,,,,399.04,,,percent of total billed charges,,,399.04,,,percent of total billed charges,,,,,,,,,159.62,,,percent of total billed charges,,,,,,,,,,,,,,,159.62,,,percent of total billed charges,,,159.62,,,percent of total billed charges,,,159.62,,,percent of total billed charges,,,299.28,,,percent of total billed charges,,,399.04,,,percent of total billed charges,,,399.04,,,percent of total billed charges,,,399.04,,,percent of total billed charges,,,,,,,,,279.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,235.11,,,percent of total billed charges,,
AMINO 8 /D14W 2000 ML LYTE,2500003138,CDM,258,RC,338020604,NDC,999,EAPG,,,,outpatient,facility,2000,UN,399.04,399.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SALINE SOLUTION IV 1000 ML,2500003140,CDM,636,RC,J7030,HCPCS,264780000,NDC,,,,inpatient,facility,1000,ML,9.01,9.01,0.72,9.01,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,,,,,,,9.01,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,
SALINE SOLUTION IV 1000 ML,2500003140,CDM,636,RC,J7030,HCPCS,264780000,NDC,,,,outpatient,facility,1000,ML,9.01,9.01,0.54,548.68,,6.39,,,percent of total billed charges,,,2.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.01,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.54,,,fee schedule,,,9.01,,,fee schedule,,,9.01,,,percent of total billed charges,,,,,,,,,9.01,,,percent of total billed charges,,,5.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,5.32,,,percent of total billed charges,,,548.68,,,per diem,,,9.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.01,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.79,,,percent of total billed charges,,,9.01,,,percent of total billed charges,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.08,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,3.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9.01,,,percent of total billed charges,,,9.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.72,,,percent of total billed charges,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.79,,,fee schedule,,,9.01,,,percent of total billed charges,,,9.01,,,percent of total billed charges,,,9.01,,,percent of total billed charges,,,,,,,,,6.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.31,,,percent of total billed charges,,
SALINE SOLUTION IV 1000 ML,2500003140,CDM,636,RC,J7030,HCPCS,264780000,NDC,496,EAPG,,outpatient,facility,1000,ML,9.01,9.01,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM ALUM 30GM/300 ML,2500003144,CDM,637,RC,2435730030,NDC,,,,,,inpatient,facility,300,UN,6765,6765,541.2,6765,,,,,,,,,,,,,,6765,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6765,,,percent of total billed charges,,,,,,,,,6765,,,percent of total billed charges,,,3454.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5761.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4059,,,percent of total billed charges,,,,,,,,,,,,,,,6765,,,percent of total billed charges,,,5750.25,,,percent of total billed charges,,,,,,,,,,,,,,,6765,,,percent of total billed charges,,,3592.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2706,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6765,,,percent of total billed charges,,,,,,,,,,,,,,,541.2,,,percent of total billed charges,,,6765,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6765,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3985.94,,,percent of total billed charges,,
POTASSIUM ALUM 30GM/300 ML,2500003144,CDM,637,RC,2435730030,NDC,,,,,,outpatient,facility,300,UN,6765,6765,357.82,6765,,4797.06,,,percent of total billed charges,,,1650.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6765,,,percent of total billed charges,,,4239.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4755.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4755.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6765,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2475.99,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6765,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6765,,,fee schedule,,,6765,,,percent of total billed charges,,,,,,,,,6765,,,percent of total billed charges,,,4146.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4820.06,,,percent of total billed charges,,,,,,,,,,,,,,,3653.1,,,percent of total billed charges,,,3517.8,,,percent of total billed charges,,,3720.75,,,percent of total billed charges,,,,,,,,,3991.35,,,percent of total billed charges,,,548.68,,,per diem,,,6765,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6765,,,percent of total billed charges,,,5750.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3592.89,,,percent of total billed charges,,,6765,,,percent of total billed charges,,,6765,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4563.67,,,percent of total billed charges,,,5474.24,,,percent of total billed charges,,,,,,,,,,,,,,,2706,,,percent of total billed charges,,,,,,,,,2503.05,,,percent of total billed charges,,,2503.05,,,percent of total billed charges,,,,,,,,,6765,,,percent of total billed charges,,,6765,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6765,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,541.2,,,percent of total billed charges,,,6765,,,percent of total billed charges,,,,,,,,,,,,,,,6765,,,percent of total billed charges,,,6765,,,percent of total billed charges,,,,,,,,,6292.8,,,percent of total billed charges,,,,,,,,,,,,,,,6292.8,,,percent of total billed charges,,,6292.8,,,percent of total billed charges,,,6292.8,,,percent of total billed charges,,,5073.75,,,percent of total billed charges,,,6765,,,percent of total billed charges,,,6765,,,percent of total billed charges,,,6765,,,percent of total billed charges,,,,,,,,,4742.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3382.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3985.94,,,percent of total billed charges,,
POTASSIUM ALUM 30GM/300 ML,2500003144,CDM,637,RC,2435730030,NDC,999,EAPG,,,,outpatient,facility,300,UN,6765,6765,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SALINE SOLUTION IV 150 ML,2500003155,CDM,258,RC,990798413,NDC,,,,,,inpatient,facility,150,UN,24.35,24.35,1.95,24.35,,,,,,,,,,,,,,24.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.35,,,percent of total billed charges,,,,,,,,,24.35,,,percent of total billed charges,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.61,,,percent of total billed charges,,,,,,,,,,,,,,,24.35,,,percent of total billed charges,,,20.7,,,percent of total billed charges,,,,,,,,,,,,,,,24.35,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,24.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,24.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.35,,,percent of total billed charges,,
SALINE SOLUTION IV 150 ML,2500003155,CDM,258,RC,990798413,NDC,,,,,,outpatient,facility,150,UN,24.35,24.35,1.95,548.68,,17.27,,,percent of total billed charges,,,5.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,24.35,,,percent of total billed charges,,,15.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,17.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,17.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,24.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,24.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,24.35,,,fee schedule,,,24.35,,,percent of total billed charges,,,,,,,,,24.35,,,percent of total billed charges,,,14.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,14.37,,,percent of total billed charges,,,548.68,,,per diem,,,24.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,24.35,,,percent of total billed charges,,,20.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,24.35,,,percent of total billed charges,,,24.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,19.7,,,percent of total billed charges,,,,,,,,,,,,,,,9.74,,,percent of total billed charges,,,,,,,,,9.74,,,percent of total billed charges,,,9.74,,,percent of total billed charges,,,,,,,,,24.35,,,percent of total billed charges,,,24.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.95,,,percent of total billed charges,,,24.35,,,percent of total billed charges,,,,,,,,,,,,,,,24.35,,,percent of total billed charges,,,24.35,,,percent of total billed charges,,,,,,,,,9.74,,,percent of total billed charges,,,,,,,,,,,,,,,9.74,,,percent of total billed charges,,,9.74,,,percent of total billed charges,,,9.74,,,percent of total billed charges,,,18.26,,,percent of total billed charges,,,24.35,,,percent of total billed charges,,,24.35,,,percent of total billed charges,,,24.35,,,percent of total billed charges,,,,,,,,,17.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.35,,,percent of total billed charges,,
SALINE SOLUTION IV 150 ML,2500003155,CDM,258,RC,990798413,NDC,999,EAPG,,,,outpatient,facility,150,UN,24.35,24.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W/NORMAL SALINE 500ML,2500003160,CDM,258,RC,J7042,HCPCS,338008903,NDC,,,,inpatient,facility,500,UN,15.61,15.61,1.25,15.61,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,,,,,,,15.61,,,percent of total billed charges,,,7.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.37,,,percent of total billed charges,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,8.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.2,,,percent of total billed charges,,
D5W/NORMAL SALINE 500ML,2500003160,CDM,258,RC,J7042,HCPCS,338008903,NDC,,,,outpatient,facility,500,UN,15.61,15.61,1.2,548.68,,11.07,,,percent of total billed charges,,,3.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,15.61,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,15.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,15.61,,,fee schedule,,,15.61,,,percent of total billed charges,,,,,,,,,15.61,,,percent of total billed charges,,,9.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,9.21,,,percent of total billed charges,,,548.68,,,per diem,,,15.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,15.61,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.29,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.53,,,percent of total billed charges,,,12.63,,,percent of total billed charges,,,,,,,,,,,,,,,6.24,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15.61,,,percent of total billed charges,,,15.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.25,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.2,,,fee schedule,,,15.61,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,,,,,,,10.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.2,,,percent of total billed charges,,
D5W/NORMAL SALINE 500ML,2500003160,CDM,258,RC,J7042,HCPCS,338008903,NDC,999,EAPG,,outpatient,facility,500,UN,15.61,15.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W/NORMAL SALINE 1000ML,2500003162,CDM,258,RC,J7042,HCPCS,264761000,NDC,,,,inpatient,facility,1000,UN,12.5,12.5,1,12.5,,,,,,,,,,,,,,12.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.5,,,percent of total billed charges,,,,,,,,,12.5,,,percent of total billed charges,,,6.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.5,,,percent of total billed charges,,,,,,,,,,,,,,,12.5,,,percent of total billed charges,,,10.62,,,percent of total billed charges,,,,,,,,,,,,,,,12.5,,,percent of total billed charges,,,6.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12.5,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,12.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.37,,,percent of total billed charges,,
D5W/NORMAL SALINE 1000ML,2500003162,CDM,258,RC,J7042,HCPCS,264761000,NDC,,,,outpatient,facility,1000,UN,12.5,12.5,1,548.68,,8.86,,,percent of total billed charges,,,3.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,12.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,12.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.58,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,12.5,,,fee schedule,,,12.5,,,percent of total billed charges,,,,,,,,,12.5,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.38,,,percent of total billed charges,,,548.68,,,per diem,,,12.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12.5,,,percent of total billed charges,,,10.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.64,,,percent of total billed charges,,,12.5,,,percent of total billed charges,,,12.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,10.12,,,percent of total billed charges,,,,,,,,,,,,,,,5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12.5,,,percent of total billed charges,,,12.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1,,,percent of total billed charges,,,12.5,,,percent of total billed charges,,,,,,,,,,,,,,,12.5,,,percent of total billed charges,,,12.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.2,,,fee schedule,,,12.5,,,percent of total billed charges,,,12.5,,,percent of total billed charges,,,12.5,,,percent of total billed charges,,,,,,,,,8.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.37,,,percent of total billed charges,,
D5W/NORMAL SALINE 1000ML,2500003162,CDM,258,RC,J7042,HCPCS,264761000,NDC,999,EAPG,,outpatient,facility,1000,UN,12.5,12.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SALINE SOLUTION IV 250 ML,2500003170,CDM,636,RC,J7050,HCPCS,264780020,NDC,,,,inpatient,facility,250,ML,9.47,9.47,0.76,9.47,,,,,,,,,,,,,,9.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.47,,,percent of total billed charges,,,,,,,,,9.47,,,percent of total billed charges,,,4.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.68,,,percent of total billed charges,,,,,,,,,,,,,,,9.47,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,9.47,,,percent of total billed charges,,,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.47,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,9.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.58,,,percent of total billed charges,,
SALINE SOLUTION IV 250 ML,2500003170,CDM,636,RC,J7050,HCPCS,264780020,NDC,,,,outpatient,facility,250,ML,9.47,9.47,0.69,548.68,,6.72,,,percent of total billed charges,,,2.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.47,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.47,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.47,,,fee schedule,,,9.47,,,percent of total billed charges,,,,,,,,,9.47,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,5.59,,,percent of total billed charges,,,548.68,,,per diem,,,9.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.47,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,9.47,,,percent of total billed charges,,,9.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.39,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9.47,,,percent of total billed charges,,,9.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.76,,,percent of total billed charges,,,9.47,,,percent of total billed charges,,,,,,,,,,,,,,,9.47,,,percent of total billed charges,,,9.47,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.69,,,fee schedule,,,9.47,,,percent of total billed charges,,,9.47,,,percent of total billed charges,,,9.47,,,percent of total billed charges,,,,,,,,,6.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.58,,,percent of total billed charges,,
SALINE SOLUTION IV 250 ML,2500003170,CDM,636,RC,J7050,HCPCS,264780020,NDC,496,EAPG,,outpatient,facility,250,ML,9.47,9.47,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W 500 ML,2500003190,CDM,258,RC,J7060,HCPCS,6521946020,NDC,,,,inpatient,facility,500,UN,12.28,12.28,0.98,12.28,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,,,,,,,12.28,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.37,,,percent of total billed charges,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,10.44,,,percent of total billed charges,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,6.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.24,,,percent of total billed charges,,
D5W 500 ML,2500003190,CDM,258,RC,J7060,HCPCS,6521946020,NDC,,,,outpatient,facility,500,UN,12.28,12.28,0.98,548.68,,8.71,,,percent of total billed charges,,,3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,12.28,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.27,,,fee schedule,,,12.28,,,fee schedule,,,12.28,,,percent of total billed charges,,,,,,,,,12.28,,,percent of total billed charges,,,7.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.25,,,percent of total billed charges,,,548.68,,,per diem,,,12.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12.28,,,percent of total billed charges,,,10.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.52,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.28,,,percent of total billed charges,,,9.94,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12.28,,,percent of total billed charges,,,12.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.98,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.74,,,fee schedule,,,12.28,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.24,,,percent of total billed charges,,
D5W 500 ML,2500003190,CDM,258,RC,J7060,HCPCS,6521946020,NDC,496,EAPG,,outpatient,facility,500,UN,12.28,12.28,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W 250 ML,2500003191,CDM,636,RC,J7060,HCPCS,264751020,NDC,,,,inpatient,facility,250,UN,11.25,11.25,0.9,11.25,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,,,,,,,11.25,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.75,,,percent of total billed charges,,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,9.56,,,percent of total billed charges,,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,
D5W 250 ML,2500003191,CDM,636,RC,J7060,HCPCS,264751020,NDC,,,,outpatient,facility,250,UN,11.25,11.25,0.9,548.68,,7.98,,,percent of total billed charges,,,2.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,11.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.12,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.27,,,fee schedule,,,11.25,,,fee schedule,,,11.25,,,percent of total billed charges,,,,,,,,,11.25,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,6.64,,,percent of total billed charges,,,548.68,,,per diem,,,11.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11.25,,,percent of total billed charges,,,9.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,9.1,,,percent of total billed charges,,,,,,,,,,,,,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11.25,,,percent of total billed charges,,,11.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.9,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.74,,,fee schedule,,,11.25,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,,,,,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.63,,,percent of total billed charges,,
D5W 250 ML,2500003191,CDM,636,RC,J7060,HCPCS,264751020,NDC,496,EAPG,,outpatient,facility,250,UN,11.25,11.25,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W 100 ML,2500003194,CDM,258,RC,J7060,HCPCS,264151032,NDC,,,,inpatient,facility,100,UN,8.15,8.15,0.65,8.15,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,8.15,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,4.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.8,,,percent of total billed charges,,
D5W 100 ML,2500003194,CDM,258,RC,J7060,HCPCS,264151032,NDC,,,,outpatient,facility,100,UN,8.15,8.15,0.65,548.68,,5.78,,,percent of total billed charges,,,1.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.98,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.27,,,fee schedule,,,8.15,,,fee schedule,,,8.15,,,percent of total billed charges,,,,,,,,,8.15,,,percent of total billed charges,,,5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,4.81,,,percent of total billed charges,,,548.68,,,per diem,,,8.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.15,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.33,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.5,,,percent of total billed charges,,,6.59,,,percent of total billed charges,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8.15,,,percent of total billed charges,,,8.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.65,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.74,,,fee schedule,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.08,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.8,,,percent of total billed charges,,
D5W 100 ML,2500003194,CDM,258,RC,J7060,HCPCS,264151032,NDC,496,EAPG,,outpatient,facility,100,UN,8.15,8.15,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W 50ML,2500003196,CDM,636,RC,J7060,HCPCS,264151031,NDC,,,,inpatient,facility,50,UN,8.15,8.15,0.65,8.15,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,8.15,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,4.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.8,,,percent of total billed charges,,
D5W 50ML,2500003196,CDM,636,RC,J7060,HCPCS,264151031,NDC,,,,outpatient,facility,50,UN,8.15,8.15,0.65,548.68,,5.78,,,percent of total billed charges,,,1.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.98,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.27,,,fee schedule,,,8.15,,,fee schedule,,,8.15,,,percent of total billed charges,,,,,,,,,8.15,,,percent of total billed charges,,,5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,4.81,,,percent of total billed charges,,,548.68,,,per diem,,,8.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.15,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.33,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.5,,,percent of total billed charges,,,6.59,,,percent of total billed charges,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8.15,,,percent of total billed charges,,,8.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.65,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.74,,,fee schedule,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.08,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.8,,,percent of total billed charges,,
D5W 50ML,2500003196,CDM,636,RC,J7060,HCPCS,264151031,NDC,496,EAPG,,outpatient,facility,50,UN,8.15,8.15,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W INFUSION 1000 ML,2500003200,CDM,258,RC,J7060,HCPCS,264751000,NDC,,,,inpatient,facility,1000,UN,13.27,13.27,1.06,13.27,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,13.27,,,percent of total billed charges,,,6.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.96,,,percent of total billed charges,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,11.28,,,percent of total billed charges,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,7.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.82,,,percent of total billed charges,,
D5W INFUSION 1000 ML,2500003200,CDM,258,RC,J7060,HCPCS,264751000,NDC,,,,outpatient,facility,1000,UN,13.27,13.27,1.06,548.68,,9.41,,,percent of total billed charges,,,3.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.27,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.86,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.27,,,fee schedule,,,13.27,,,fee schedule,,,13.27,,,percent of total billed charges,,,,,,,,,13.27,,,percent of total billed charges,,,8.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.83,,,percent of total billed charges,,,548.68,,,per diem,,,13.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.27,,,percent of total billed charges,,,11.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.05,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.95,,,percent of total billed charges,,,10.74,,,percent of total billed charges,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13.27,,,percent of total billed charges,,,13.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.06,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.74,,,fee schedule,,,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,9.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.82,,,percent of total billed charges,,
D5W INFUSION 1000 ML,2500003200,CDM,258,RC,J7060,HCPCS,264751000,NDC,496,EAPG,,outpatient,facility,1000,UN,13.27,13.27,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RINGERS LACTATE INFUS 1000 ML,2500003230,CDM,636,RC,J7120,HCPCS,264775000,NDC,,,,inpatient,facility,1000,ML,10.03,10.03,0.8,10.03,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,,,,,,,10.03,,,percent of total billed charges,,,5.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,8.53,,,percent of total billed charges,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,5.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,
RINGERS LACTATE INFUS 1000 ML,2500003230,CDM,636,RC,J7120,HCPCS,264775000,NDC,,,,outpatient,facility,1000,ML,10.03,10.03,0.8,548.68,,7.11,,,percent of total billed charges,,,2.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.03,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.67,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.03,,,fee schedule,,,10.03,,,percent of total billed charges,,,,,,,,,10.03,,,percent of total billed charges,,,6.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,5.92,,,percent of total billed charges,,,548.68,,,per diem,,,10.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.03,,,percent of total billed charges,,,8.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.33,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.77,,,percent of total billed charges,,,8.12,,,percent of total billed charges,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10.03,,,percent of total billed charges,,,10.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.8,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.55,,,fee schedule,,,10.03,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.91,,,percent of total billed charges,,
RINGERS LACTATE INFUS 1000 ML,2500003230,CDM,636,RC,J7120,HCPCS,264775000,NDC,496,EAPG,,outpatient,facility,1000,ML,10.03,10.03,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RINGERS LACTATE INFUS 500 ML,2500003231,CDM,636,RC,J7120,HCPCS,338011703,NDC,,,,inpatient,facility,500,ML,15.21,15.21,1.22,15.21,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,,,,,,,15.21,,,percent of total billed charges,,,7.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.13,,,percent of total billed charges,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,8.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.96,,,percent of total billed charges,,
RINGERS LACTATE INFUS 500 ML,2500003231,CDM,636,RC,J7120,HCPCS,338011703,NDC,,,,outpatient,facility,500,ML,15.21,15.21,1.22,548.68,,10.79,,,percent of total billed charges,,,3.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,15.21,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,15.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,15.21,,,fee schedule,,,15.21,,,percent of total billed charges,,,,,,,,,15.21,,,percent of total billed charges,,,9.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,8.97,,,percent of total billed charges,,,548.68,,,per diem,,,15.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,15.21,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.08,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.26,,,percent of total billed charges,,,12.31,,,percent of total billed charges,,,,,,,,,,,,,,,6.08,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15.21,,,percent of total billed charges,,,15.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.22,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.55,,,fee schedule,,,15.21,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,,,,,,,10.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.96,,,percent of total billed charges,,
RINGERS LACTATE INFUS 500 ML,2500003231,CDM,636,RC,J7120,HCPCS,338011703,NDC,496,EAPG,,outpatient,facility,500,ML,15.21,15.21,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SP-LEUPROLIDE 3.75 MG INJ,2500003294,CDM,636,RC,J9218,HCPCS,74364103,NDC,,,,inpatient,facility,3.75,UN,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-LEUPROLIDE 3.75 MG INJ,2500003294,CDM,636,RC,J9218,HCPCS,74364103,NDC,,,,outpatient,facility,3.75,UN,0.01,0.01,0.01,548.68,,11.02,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,6.04,,,fee schedule,,,5.71,,,fee schedule,,,,,,,,,5.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-LEUPROLIDE 3.75 MG INJ,2500003294,CDM,636,RC,J9218,HCPCS,74364103,NDC,430,EAPG,,outpatient,facility,3.75,UN,0.01,0.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COVID-19 30MCG/ 0.3ML PFIZFER,2500003306,CDM,636,RC,91300,CPT,,,,,,inpatient,facility,,,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
COVID-19 30MCG/ 0.3ML PFIZFER,2500003306,CDM,636,RC,91300,CPT,,,,,,outpatient,facility,,,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
COVID-19 30MCG/ 0.3ML PFIZFER,2500003306,CDM,636,RC,91300,CPT,999,EAPG,,,,outpatient,facility,,,0.01,0.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COVID-19 100MCG/0.5ML MODERNA,2500003307,CDM,636,RC,91301,CPT,,,,,,inpatient,facility,,,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
COVID-19 100MCG/0.5ML MODERNA,2500003307,CDM,636,RC,91301,CPT,,,,,,outpatient,facility,,,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
COVID-19 100MCG/0.5ML MODERNA,2500003307,CDM,636,RC,91301,CPT,999,EAPG,,,,outpatient,facility,,,0.01,0.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
(R)riTUXimab-PVVR 100 MG/10 ML,2500003316,CDM,636,RC,Q5119,HCPCS,69023801,NDC,,,,inpatient,facility,10,UN,2365.44,2365.44,189.24,2365.44,,,,,,,,,,,,,,2365.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2365.44,,,percent of total billed charges,,,,,,,,,2365.44,,,percent of total billed charges,,,1207.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2014.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1419.26,,,percent of total billed charges,,,,,,,,,,,,,,,2365.44,,,percent of total billed charges,,,2010.62,,,percent of total billed charges,,,,,,,,,,,,,,,2365.44,,,percent of total billed charges,,,1256.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,946.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2365.44,,,percent of total billed charges,,,,,,,,,,,,,,,189.24,,,percent of total billed charges,,,2365.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2365.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1393.72,,,percent of total billed charges,,
(R)riTUXimab-PVVR 100 MG/10 ML,2500003316,CDM,636,RC,Q5119,HCPCS,69023801,NDC,,,,outpatient,facility,10,UN,2365.44,2365.44,19.98,2365.44,,20.28,,,fee schedule,,,,,,,,,2365.44,,,percent of total billed charges,,,24.99,,,fee schedule,,,23.64,,,fee schedule,,,,,,,,,23.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2365.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2365.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2365.44,,,fee schedule,,,2365.44,,,percent of total billed charges,,,,,,,,,2365.44,,,percent of total billed charges,,,1449.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1685.38,,,percent of total billed charges,,,,,,,,,,,,,,,20.45,,,fee schedule,,,20.45,,,fee schedule,,,20.45,,,fee schedule,,,,,,,,,1395.61,,,percent of total billed charges,,,548.68,,,per diem,,,2365.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2365.44,,,percent of total billed charges,,,2010.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1256.29,,,percent of total billed charges,,,2365.44,,,percent of total billed charges,,,2365.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1595.73,,,percent of total billed charges,,,1914.11,,,percent of total billed charges,,,,,,,,,,,,,,,946.18,,,percent of total billed charges,,,,,,,,,97.64,,,fee schedule,,,70.26,,,fee schedule,,,,,,,,,2365.44,,,percent of total billed charges,,,,,,,,,,,,,,,189.24,,,percent of total billed charges,,,2365.44,,,percent of total billed charges,,,,,,,,,,,,,,,2365.44,,,percent of total billed charges,,,2365.44,,,percent of total billed charges,,,,,,,,,41.73,,,fee schedule,,,,,,,,,,,,,,,36.17,,,fee schedule,,,48.22,,,fee schedule,,,27.12,,,fee schedule,,,19.98,,,fee schedule,,,2365.44,,,percent of total billed charges,,,2365.44,,,percent of total billed charges,,,2365.44,,,percent of total billed charges,,,,,,,,,1658.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1393.72,,,percent of total billed charges,,
(R)riTUXimab-PVVR 100 MG/10 ML,2500003316,CDM,636,RC,Q5119,HCPCS,69023801,NDC,9367,APC,,outpatient,facility,10,UN,2365.44,2365.44,22.65,865.75,,,,,,,,24.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,23.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,865.75,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,23.59,,,fee schedule,,,,,,,,,,,,,,,24.77,,,fee schedule,,,24.77,,,fee schedule,,,,,,,,,23.59,,,fee schedule,,,23.59,,,fee schedule,,,24.77,,,fee schedule,,,,,,,,,,,,,,,35.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,23.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.65,,,fee schedule,,,25.24,,,fee schedule,,,24.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.59,,,fee schedule,,,23.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,24.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,23.59,,,fee schedule,,,,,,,,,29.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,23.59,,,fee schedule,,,23.59,,,fee schedule,,,,,,,,,,,,,,,23.59,,,fee schedule,,,,,,,,,23.59,,,fee schedule,,,24.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.59,,,fee schedule,,,,,,,,,,,,,,,24.53,,,fee schedule,,,23.59,,,fee schedule,,,,,,,,,23.59,,,fee schedule,,,,,,,,,23.59,,,fee schedule,,,24.77,,,fee schedule,,,,,,,,
(R)riTUXimab-PVVR 100 MG/10 ML,2500003316,CDM,636,RC,Q5119,HCPCS,69023801,NDC,461,EAPG,,outpatient,facility,10,UN,2365.44,2365.44,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
(R)riTUXimab-PVVR 500 MG/50 ML,2500003317,CDM,636,RC,Q5119,HCPCS,69024901,NDC,,,,inpatient,facility,50,ML,11827.2,11827.2,946.18,11827.2,,,,,,,,,,,,,,11827.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11827.2,,,percent of total billed charges,,,,,,,,,11827.2,,,percent of total billed charges,,,6038.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10073.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7096.32,,,percent of total billed charges,,,,,,,,,,,,,,,11827.2,,,percent of total billed charges,,,10053.12,,,percent of total billed charges,,,,,,,,,,,,,,,11827.2,,,percent of total billed charges,,,6281.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4730.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11827.2,,,percent of total billed charges,,,,,,,,,,,,,,,946.18,,,percent of total billed charges,,,11827.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11827.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6968.59,,,percent of total billed charges,,
(R)riTUXimab-PVVR 500 MG/50 ML,2500003317,CDM,636,RC,Q5119,HCPCS,69024901,NDC,,,,outpatient,facility,50,ML,11827.2,11827.2,19.98,11827.2,,20.28,,,fee schedule,,,,,,,,,11827.2,,,percent of total billed charges,,,24.99,,,fee schedule,,,23.64,,,fee schedule,,,,,,,,,23.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,11827.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11827.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,11827.2,,,fee schedule,,,11827.2,,,percent of total billed charges,,,,,,,,,11827.2,,,percent of total billed charges,,,7248.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8426.88,,,percent of total billed charges,,,,,,,,,,,,,,,20.45,,,fee schedule,,,20.45,,,fee schedule,,,20.45,,,fee schedule,,,,,,,,,6978.05,,,percent of total billed charges,,,548.68,,,per diem,,,11827.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11827.2,,,percent of total billed charges,,,10053.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6281.43,,,percent of total billed charges,,,11827.2,,,percent of total billed charges,,,11827.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7978.63,,,percent of total billed charges,,,9570.57,,,percent of total billed charges,,,,,,,,,,,,,,,4730.88,,,percent of total billed charges,,,,,,,,,97.64,,,fee schedule,,,70.26,,,fee schedule,,,,,,,,,11827.2,,,percent of total billed charges,,,,,,,,,,,,,,,946.18,,,percent of total billed charges,,,11827.2,,,percent of total billed charges,,,,,,,,,,,,,,,11827.2,,,percent of total billed charges,,,11827.2,,,percent of total billed charges,,,,,,,,,41.73,,,fee schedule,,,,,,,,,,,,,,,36.17,,,fee schedule,,,48.22,,,fee schedule,,,27.12,,,fee schedule,,,19.98,,,fee schedule,,,11827.2,,,percent of total billed charges,,,11827.2,,,percent of total billed charges,,,11827.2,,,percent of total billed charges,,,,,,,,,8292.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5913.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6968.59,,,percent of total billed charges,,
(R)riTUXimab-PVVR 500 MG/50 ML,2500003317,CDM,636,RC,Q5119,HCPCS,69024901,NDC,9367,APC,,outpatient,facility,50,ML,11827.2,11827.2,22.65,4328.76,,,,,,,,24.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,23.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,fee schedule,,,,,,,,,4328.76,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,23.59,,,fee schedule,,,,,,,,,,,,,,,24.77,,,fee schedule,,,24.77,,,fee schedule,,,,,,,,,23.59,,,fee schedule,,,23.59,,,fee schedule,,,24.77,,,fee schedule,,,,,,,,,,,,,,,35.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,23.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.65,,,fee schedule,,,25.24,,,fee schedule,,,24.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.59,,,fee schedule,,,23.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,24.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,23.59,,,fee schedule,,,,,,,,,29.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,23.59,,,fee schedule,,,23.59,,,fee schedule,,,,,,,,,,,,,,,23.59,,,fee schedule,,,,,,,,,23.59,,,fee schedule,,,24.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.59,,,fee schedule,,,,,,,,,,,,,,,24.53,,,fee schedule,,,23.59,,,fee schedule,,,,,,,,,23.59,,,fee schedule,,,,,,,,,23.59,,,fee schedule,,,24.77,,,fee schedule,,,,,,,,
(R)riTUXimab-PVVR 500 MG/50 ML,2500003317,CDM,636,RC,Q5119,HCPCS,69024901,NDC,461,EAPG,,outpatient,facility,50,ML,11827.2,11827.2,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
(R)BEVACIZUMAB-BVZR 100MG/4 ML,2500003320,CDM,636,RC,Q5118,HCPCS,69031501,NDC,,,,inpatient,facility,4,GR,2024.22,2024.22,161.94,2024.22,,,,,,,,,,,,,,2024.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2024.22,,,percent of total billed charges,,,,,,,,,2024.22,,,percent of total billed charges,,,1033.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1724.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1214.53,,,percent of total billed charges,,,,,,,,,,,,,,,2024.22,,,percent of total billed charges,,,1720.59,,,percent of total billed charges,,,,,,,,,,,,,,,2024.22,,,percent of total billed charges,,,1075.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,809.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2024.22,,,percent of total billed charges,,,,,,,,,,,,,,,161.94,,,percent of total billed charges,,,2024.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2024.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1192.67,,,percent of total billed charges,,
(R)BEVACIZUMAB-BVZR 100MG/4 ML,2500003320,CDM,636,RC,Q5118,HCPCS,69031501,NDC,,,,outpatient,facility,4,GR,2024.22,2024.22,20.76,2024.22,,20.76,,,fee schedule,,,,,,,,,2024.22,,,percent of total billed charges,,,27.22,,,fee schedule,,,25.75,,,fee schedule,,,,,,,,,25.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2024.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2024.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2024.22,,,fee schedule,,,2024.22,,,percent of total billed charges,,,,,,,,,2024.22,,,percent of total billed charges,,,1240.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1442.26,,,percent of total billed charges,,,,,,,,,,,,,,,21.51,,,fee schedule,,,21.51,,,fee schedule,,,21.51,,,fee schedule,,,,,,,,,1194.29,,,percent of total billed charges,,,548.68,,,per diem,,,2024.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2024.22,,,percent of total billed charges,,,1720.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1075.06,,,percent of total billed charges,,,2024.22,,,percent of total billed charges,,,2024.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1365.54,,,percent of total billed charges,,,1638,,,percent of total billed charges,,,,,,,,,,,,,,,809.69,,,percent of total billed charges,,,,,,,,,94.99,,,fee schedule,,,68.35,,,fee schedule,,,,,,,,,2024.22,,,percent of total billed charges,,,,,,,,,,,,,,,161.94,,,percent of total billed charges,,,2024.22,,,percent of total billed charges,,,,,,,,,,,,,,,2024.22,,,percent of total billed charges,,,2024.22,,,percent of total billed charges,,,,,,,,,40.59,,,fee schedule,,,,,,,,,,,,,,,35.18,,,fee schedule,,,46.91,,,fee schedule,,,26.38,,,fee schedule,,,21.76,,,fee schedule,,,2024.22,,,percent of total billed charges,,,2024.22,,,percent of total billed charges,,,2024.22,,,percent of total billed charges,,,,,,,,,1419.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1012.11,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1192.67,,,percent of total billed charges,,
(R)BEVACIZUMAB-BVZR 100MG/4 ML,2500003320,CDM,636,RC,Q5118,HCPCS,69031501,NDC,9348,APC,,outpatient,facility,4,GR,2024.22,2024.22,22.08,740.86,,,,,,,,23.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.23,,,fee schedule,,,,,,,,,740.86,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,23,,,fee schedule,,,,,,,,,,,,,,,24.15,,,fee schedule,,,24.15,,,fee schedule,,,,,,,,,23,,,fee schedule,,,23,,,fee schedule,,,24.15,,,fee schedule,,,,,,,,,,,,,,,34.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.08,,,fee schedule,,,24.61,,,fee schedule,,,24.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23,,,fee schedule,,,23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,23.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,23,,,fee schedule,,,,,,,,,28.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,23,,,fee schedule,,,23,,,fee schedule,,,,,,,,,,,,,,,23,,,fee schedule,,,,,,,,,23,,,fee schedule,,,23.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23,,,fee schedule,,,,,,,,,,,,,,,23.92,,,fee schedule,,,23,,,fee schedule,,,,,,,,,23,,,fee schedule,,,,,,,,,23,,,fee schedule,,,24.15,,,fee schedule,,,,,,,,
(R)BEVACIZUMAB-BVZR 100MG/4 ML,2500003320,CDM,636,RC,Q5118,HCPCS,69031501,NDC,444,EAPG,,outpatient,facility,4,GR,2024.22,2024.22,1304.36,1969.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1969.58,,,fee schedule,,,1304.36,,,fee schedule,,,1750.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
(R)BEVACIZUMAB-BVZR 400 MG/16,2500003321,CDM,636,RC,Q5118,HCPCS,69034201,NDC,,,,inpatient,facility,16,ML,8096.88,8096.88,647.75,8096.88,,,,,,,,,,,,,,8096.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8096.88,,,percent of total billed charges,,,,,,,,,8096.88,,,percent of total billed charges,,,4134.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6896.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4858.13,,,percent of total billed charges,,,,,,,,,,,,,,,8096.88,,,percent of total billed charges,,,6882.35,,,percent of total billed charges,,,,,,,,,,,,,,,8096.88,,,percent of total billed charges,,,4300.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3238.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8096.88,,,percent of total billed charges,,,,,,,,,,,,,,,647.75,,,percent of total billed charges,,,8096.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8096.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4770.68,,,percent of total billed charges,,
(R)BEVACIZUMAB-BVZR 400 MG/16,2500003321,CDM,636,RC,Q5118,HCPCS,69034201,NDC,,,,outpatient,facility,16,ML,8096.88,8096.88,20.76,8096.88,,20.76,,,fee schedule,,,,,,,,,8096.88,,,percent of total billed charges,,,27.22,,,fee schedule,,,25.75,,,fee schedule,,,,,,,,,25.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,8096.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8096.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8096.88,,,fee schedule,,,8096.88,,,percent of total billed charges,,,,,,,,,8096.88,,,percent of total billed charges,,,4962.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5769.03,,,percent of total billed charges,,,,,,,,,,,,,,,21.51,,,fee schedule,,,21.51,,,fee schedule,,,21.51,,,fee schedule,,,,,,,,,4777.16,,,percent of total billed charges,,,548.68,,,per diem,,,8096.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8096.88,,,percent of total billed charges,,,6882.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4300.25,,,percent of total billed charges,,,8096.88,,,percent of total billed charges,,,8096.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5462.16,,,percent of total billed charges,,,6552,,,percent of total billed charges,,,,,,,,,,,,,,,3238.75,,,percent of total billed charges,,,,,,,,,94.99,,,fee schedule,,,68.35,,,fee schedule,,,,,,,,,8096.88,,,percent of total billed charges,,,,,,,,,,,,,,,647.75,,,percent of total billed charges,,,8096.88,,,percent of total billed charges,,,,,,,,,,,,,,,8096.88,,,percent of total billed charges,,,8096.88,,,percent of total billed charges,,,,,,,,,40.59,,,fee schedule,,,,,,,,,,,,,,,35.18,,,fee schedule,,,46.91,,,fee schedule,,,26.38,,,fee schedule,,,21.76,,,fee schedule,,,8096.88,,,percent of total billed charges,,,8096.88,,,percent of total billed charges,,,8096.88,,,percent of total billed charges,,,,,,,,,5676.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4048.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4770.68,,,percent of total billed charges,,
(R)BEVACIZUMAB-BVZR 400 MG/16,2500003321,CDM,636,RC,Q5118,HCPCS,69034201,NDC,9348,APC,,outpatient,facility,16,ML,8096.88,8096.88,22.08,2963.46,,,,,,,,23.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.23,,,fee schedule,,,,,,,,,2963.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,23,,,fee schedule,,,,,,,,,,,,,,,24.15,,,fee schedule,,,24.15,,,fee schedule,,,,,,,,,23,,,fee schedule,,,23,,,fee schedule,,,24.15,,,fee schedule,,,,,,,,,,,,,,,34.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.08,,,fee schedule,,,24.61,,,fee schedule,,,24.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23,,,fee schedule,,,23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,23.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,23,,,fee schedule,,,,,,,,,28.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,23,,,fee schedule,,,23,,,fee schedule,,,,,,,,,,,,,,,23,,,fee schedule,,,,,,,,,23,,,fee schedule,,,23.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23,,,fee schedule,,,,,,,,,,,,,,,23.92,,,fee schedule,,,23,,,fee schedule,,,,,,,,,23,,,fee schedule,,,,,,,,,23,,,fee schedule,,,24.15,,,fee schedule,,,,,,,,
(R)BEVACIZUMAB-BVZR 400 MG/16,2500003321,CDM,636,RC,Q5118,HCPCS,69034201,NDC,444,EAPG,,outpatient,facility,16,ML,8096.88,8096.88,1304.36,1969.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1969.58,,,fee schedule,,,1304.36,,,fee schedule,,,1750.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AZATHIOPRINE 50 MG TAB,2500003322,CDM,637,RC,J7500,HCPCS,6838200301,NDC,,,,inpatient,facility,50,UN,6.96,6.96,0.56,6.96,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,6.96,,,percent of total billed charges,,,3.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.18,,,percent of total billed charges,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,5.92,,,percent of total billed charges,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,3.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.1,,,percent of total billed charges,,
AZATHIOPRINE 50 MG TAB,2500003322,CDM,637,RC,J7500,HCPCS,6838200301,NDC,,,,outpatient,facility,50,UN,6.96,6.96,0.56,548.68,,4.94,,,percent of total billed charges,,,1.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.96,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.55,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.96,,,fee schedule,,,6.96,,,percent of total billed charges,,,,,,,,,6.96,,,percent of total billed charges,,,4.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,4.11,,,percent of total billed charges,,,548.68,,,per diem,,,6.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.96,,,percent of total billed charges,,,5.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.7,,,percent of total billed charges,,,5.63,,,percent of total billed charges,,,,,,,,,,,,,,,2.78,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6.96,,,percent of total billed charges,,,6.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.9,,,fee schedule,,,6.96,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,,,,,,,4.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.1,,,percent of total billed charges,,
AZATHIOPRINE 50 MG TAB,2500003322,CDM,637,RC,J7500,HCPCS,6838200301,NDC,496,EAPG,,outpatient,facility,50,UN,6.96,6.96,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXEPIN 3MG TABLET,2500003333,CDM,637,RC,4418310330,NDC,,,,,,inpatient,facility,3,UN,53.79,53.79,4.3,53.79,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,,,,,,,53.79,,,percent of total billed charges,,,27.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.27,,,percent of total billed charges,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,45.72,,,percent of total billed charges,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,28.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.69,,,percent of total billed charges,,
DOXEPIN 3MG TABLET,2500003333,CDM,637,RC,4418310330,NDC,,,,,,outpatient,facility,3,UN,53.79,53.79,4.3,548.68,,38.14,,,percent of total billed charges,,,13.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,53.79,,,percent of total billed charges,,,33.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,37.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,37.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,19.69,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,53.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,53.79,,,fee schedule,,,53.79,,,percent of total billed charges,,,,,,,,,53.79,,,percent of total billed charges,,,32.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.33,,,percent of total billed charges,,,,,,,,,,,,,,,29.05,,,percent of total billed charges,,,27.97,,,percent of total billed charges,,,29.58,,,percent of total billed charges,,,,,,,,,31.74,,,percent of total billed charges,,,548.68,,,per diem,,,53.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,53.79,,,percent of total billed charges,,,45.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.57,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.29,,,percent of total billed charges,,,43.53,,,percent of total billed charges,,,,,,,,,,,,,,,21.52,,,percent of total billed charges,,,,,,,,,19.9,,,percent of total billed charges,,,19.9,,,percent of total billed charges,,,,,,,,,53.79,,,percent of total billed charges,,,53.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,53.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.3,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,,,,,,,50.04,,,percent of total billed charges,,,,,,,,,,,,,,,50.04,,,percent of total billed charges,,,50.04,,,percent of total billed charges,,,50.04,,,percent of total billed charges,,,40.34,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,,,,,,,37.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,31.69,,,percent of total billed charges,,
DOXEPIN 3MG TABLET,2500003333,CDM,637,RC,4418310330,NDC,999,EAPG,,,,outpatient,facility,3,UN,53.79,53.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRANEXAMIC ACID 1000 MG/10 ML,2500003334,CDM,250,RC,13111415,NDC,,,,,,inpatient,facility,10,UN,67.32,67.32,5.39,67.32,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,,,,,,,67.32,,,percent of total billed charges,,,34.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.39,,,percent of total billed charges,,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,57.22,,,percent of total billed charges,,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,35.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,5.39,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.66,,,percent of total billed charges,,
TRANEXAMIC ACID 1000 MG/10 ML,2500003334,CDM,250,RC,13111415,NDC,,,,,,outpatient,facility,10,UN,67.32,67.32,5.39,548.68,,47.74,,,percent of total billed charges,,,16.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,67.32,,,percent of total billed charges,,,42.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,47.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,47.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,24.64,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,67.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,67.32,,,fee schedule,,,67.32,,,percent of total billed charges,,,,,,,,,67.32,,,percent of total billed charges,,,41.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,39.72,,,percent of total billed charges,,,548.68,,,per diem,,,67.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,67.32,,,percent of total billed charges,,,57.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.75,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.41,,,percent of total billed charges,,,54.48,,,percent of total billed charges,,,,,,,,,,,,,,,26.93,,,percent of total billed charges,,,,,,,,,26.93,,,percent of total billed charges,,,26.93,,,percent of total billed charges,,,,,,,,,67.32,,,percent of total billed charges,,,67.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,67.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.39,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,67.32,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,,,,,,,26.93,,,percent of total billed charges,,,,,,,,,,,,,,,26.93,,,percent of total billed charges,,,26.93,,,percent of total billed charges,,,26.93,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,,,,,,,47.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,39.66,,,percent of total billed charges,,
TRANEXAMIC ACID 1000 MG/10 ML,2500003334,CDM,250,RC,13111415,NDC,999,EAPG,,,,outpatient,facility,10,UN,67.32,67.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE/MELOXICAM 7 ML INJ,2500003336,CDM,250,RC,4742630301,NDC,,,,,,inpatient,facility,7,UN,469.49,469.49,37.56,469.49,,,,,,,,,,,,,,469.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,469.49,,,percent of total billed charges,,,,,,,,,469.49,,,percent of total billed charges,,,239.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,399.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.69,,,percent of total billed charges,,,,,,,,,,,,,,,469.49,,,percent of total billed charges,,,399.07,,,percent of total billed charges,,,,,,,,,,,,,,,469.49,,,percent of total billed charges,,,249.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,469.49,,,percent of total billed charges,,,,,,,,,,,,,,,37.56,,,percent of total billed charges,,,469.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,469.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.62,,,percent of total billed charges,,
BUPIVACAINE/MELOXICAM 7 ML INJ,2500003336,CDM,250,RC,4742630301,NDC,,,,,,outpatient,facility,7,UN,469.49,469.49,37.56,548.68,,332.92,,,percent of total billed charges,,,114.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,469.49,,,percent of total billed charges,,,294.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,330.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,330.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,469.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,171.83,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,469.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,469.49,,,fee schedule,,,469.49,,,percent of total billed charges,,,,,,,,,469.49,,,percent of total billed charges,,,287.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,277,,,percent of total billed charges,,,548.68,,,per diem,,,469.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,469.49,,,percent of total billed charges,,,399.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,249.35,,,percent of total billed charges,,,469.49,,,percent of total billed charges,,,469.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.72,,,percent of total billed charges,,,379.91,,,percent of total billed charges,,,,,,,,,,,,,,,187.8,,,percent of total billed charges,,,,,,,,,187.8,,,percent of total billed charges,,,187.8,,,percent of total billed charges,,,,,,,,,469.49,,,percent of total billed charges,,,469.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,469.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,37.56,,,percent of total billed charges,,,469.49,,,percent of total billed charges,,,,,,,,,,,,,,,469.49,,,percent of total billed charges,,,469.49,,,percent of total billed charges,,,,,,,,,187.8,,,percent of total billed charges,,,,,,,,,,,,,,,187.8,,,percent of total billed charges,,,187.8,,,percent of total billed charges,,,187.8,,,percent of total billed charges,,,352.12,,,percent of total billed charges,,,469.49,,,percent of total billed charges,,,469.49,,,percent of total billed charges,,,469.49,,,percent of total billed charges,,,,,,,,,329.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,276.62,,,percent of total billed charges,,
BUPIVACAINE/MELOXICAM 7 ML INJ,2500003336,CDM,250,RC,4742630301,NDC,999,EAPG,,,,outpatient,facility,7,UN,469.49,469.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DICLOFENAC GEL 1   50GM,2500003339,CDM,637,RC,7000005551,NDC,,,,,,inpatient,facility,50,UN,31.98,31.98,2.56,31.98,,,,,,,,,,,,,,31.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.98,,,percent of total billed charges,,,,,,,,,31.98,,,percent of total billed charges,,,16.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.19,,,percent of total billed charges,,,,,,,,,,,,,,,31.98,,,percent of total billed charges,,,27.18,,,percent of total billed charges,,,,,,,,,,,,,,,31.98,,,percent of total billed charges,,,16.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,31.98,,,percent of total billed charges,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,31.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.84,,,percent of total billed charges,,
DICLOFENAC GEL 1   50GM,2500003339,CDM,637,RC,7000005551,NDC,,,,,,outpatient,facility,50,UN,31.98,31.98,2.56,548.68,,22.68,,,percent of total billed charges,,,7.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,31.98,,,percent of total billed charges,,,20.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,22.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,22.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,31.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.7,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,31.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,31.98,,,fee schedule,,,31.98,,,percent of total billed charges,,,,,,,,,31.98,,,percent of total billed charges,,,19.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.79,,,percent of total billed charges,,,,,,,,,,,,,,,17.27,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,17.59,,,percent of total billed charges,,,,,,,,,18.87,,,percent of total billed charges,,,548.68,,,per diem,,,31.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,31.98,,,percent of total billed charges,,,27.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.98,,,percent of total billed charges,,,31.98,,,percent of total billed charges,,,31.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.57,,,percent of total billed charges,,,25.88,,,percent of total billed charges,,,,,,,,,,,,,,,12.79,,,percent of total billed charges,,,,,,,,,11.83,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,,,,,,,31.98,,,percent of total billed charges,,,31.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.56,,,percent of total billed charges,,,31.98,,,percent of total billed charges,,,,,,,,,,,,,,,31.98,,,percent of total billed charges,,,31.98,,,percent of total billed charges,,,,,,,,,29.75,,,percent of total billed charges,,,,,,,,,,,,,,,29.75,,,percent of total billed charges,,,29.75,,,percent of total billed charges,,,29.75,,,percent of total billed charges,,,23.98,,,percent of total billed charges,,,31.98,,,percent of total billed charges,,,31.98,,,percent of total billed charges,,,31.98,,,percent of total billed charges,,,,,,,,,22.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.84,,,percent of total billed charges,,
DICLOFENAC GEL 1   50GM,2500003339,CDM,637,RC,7000005551,NDC,999,EAPG,,,,outpatient,facility,50,UN,31.98,31.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LURBINECTEDIN 4MG VIAL,2500003343,CDM,636,RC,J9223,HCPCS,6872771201,NDC,,,,inpatient,facility,4,GR,26499,26499,2119.92,26499,,,,,,,,,,,,,,26499,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26499,,,percent of total billed charges,,,,,,,,,26499,,,percent of total billed charges,,,13530.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22569.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15899.4,,,percent of total billed charges,,,,,,,,,,,,,,,26499,,,percent of total billed charges,,,22524.15,,,percent of total billed charges,,,,,,,,,,,,,,,26499,,,percent of total billed charges,,,14073.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10599.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,26499,,,percent of total billed charges,,,,,,,,,,,,,,,2119.92,,,percent of total billed charges,,,26499,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26499,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15613.21,,,percent of total billed charges,,
LURBINECTEDIN 4MG VIAL,2500003343,CDM,636,RC,J9223,HCPCS,6872771201,NDC,,,,outpatient,facility,4,GR,26499,26499,125.73,26499,,199.52,,,fee schedule,,,,,,,,,26499,,,percent of total billed charges,,,263.18,,,fee schedule,,,248.99,,,fee schedule,,,,,,,,,248.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,26499,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,26499,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,26499,,,fee schedule,,,26499,,,percent of total billed charges,,,,,,,,,26499,,,percent of total billed charges,,,16241.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18880.54,,,percent of total billed charges,,,,,,,,,,,,,,,200.01,,,fee schedule,,,200.01,,,fee schedule,,,200.01,,,fee schedule,,,,,,,,,15634.41,,,percent of total billed charges,,,548.68,,,per diem,,,26499,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,26499,,,percent of total billed charges,,,22524.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14073.62,,,percent of total billed charges,,,26499,,,percent of total billed charges,,,26499,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17876.23,,,percent of total billed charges,,,21442.99,,,percent of total billed charges,,,,,,,,,,,,,,,10599.6,,,percent of total billed charges,,,,,,,,,452.63,,,fee schedule,,,325.7,,,fee schedule,,,,,,,,,26499,,,percent of total billed charges,,,,,,,,,,,,,,,2119.92,,,percent of total billed charges,,,26499,,,percent of total billed charges,,,,,,,,,,,,,,,26499,,,percent of total billed charges,,,26499,,,percent of total billed charges,,,,,,,,,193.43,,,fee schedule,,,,,,,,,,,,,,,167.65,,,fee schedule,,,223.53,,,fee schedule,,,125.73,,,fee schedule,,,210.41,,,fee schedule,,,26499,,,percent of total billed charges,,,26499,,,percent of total billed charges,,,26499,,,percent of total billed charges,,,,,,,,,18578.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13249.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15613.21,,,percent of total billed charges,,
LURBINECTEDIN 4MG VIAL,2500003343,CDM,636,RC,J9223,HCPCS,6872771201,NDC,9389,APC,,outpatient,facility,4,GR,26499,26499,196.7,9698.63,,,,,,,,211.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,204.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.95,,,fee schedule,,,,,,,,,9698.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,204.9,,,fee schedule,,,,,,,,,,,,,,,215.14,,,fee schedule,,,215.14,,,fee schedule,,,,,,,,,204.9,,,fee schedule,,,204.9,,,fee schedule,,,215.14,,,fee schedule,,,,,,,,,,,,,,,307.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,204.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.7,,,fee schedule,,,219.24,,,fee schedule,,,215.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,204.9,,,fee schedule,,,204.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,213.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,204.9,,,fee schedule,,,,,,,,,256.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,256.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,204.9,,,fee schedule,,,204.9,,,fee schedule,,,,,,,,,,,,,,,204.9,,,fee schedule,,,,,,,,,204.9,,,fee schedule,,,211.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,204.9,,,fee schedule,,,,,,,,,,,,,,,213.1,,,fee schedule,,,204.9,,,fee schedule,,,,,,,,,204.9,,,fee schedule,,,,,,,,,204.9,,,fee schedule,,,215.14,,,fee schedule,,,,,,,,
LURBINECTEDIN 4MG VIAL,2500003343,CDM,636,RC,J9223,HCPCS,6872771201,NDC,462,EAPG,,outpatient,facility,4,GR,26499,26499,4530.01,6840.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6840.32,,,fee schedule,,,4530.01,,,fee schedule,,,6081.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CYCLOSPORINE ORAL 25 MG,2500003344,CDM,637,RC,J7515,HCPCS,5186245847,NDC,,,,inpatient,facility,25,UN,4.55,4.55,0.36,4.55,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,,,,,,,4.55,,,percent of total billed charges,,,2.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,
CYCLOSPORINE ORAL 25 MG,2500003344,CDM,637,RC,J7515,HCPCS,5186245847,NDC,,,,outpatient,facility,25,UN,4.55,4.55,0.36,548.68,,3.23,,,percent of total billed charges,,,1.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.55,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.67,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.55,,,fee schedule,,,4.55,,,percent of total billed charges,,,,,,,,,4.55,,,percent of total billed charges,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,2.68,,,percent of total billed charges,,,548.68,,,per diem,,,4.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.55,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.42,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4.55,,,percent of total billed charges,,,4.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.36,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.83,,,fee schedule,,,4.55,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,,,,,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.68,,,percent of total billed charges,,
CYCLOSPORINE ORAL 25 MG,2500003344,CDM,637,RC,J7515,HCPCS,5186245847,NDC,496,EAPG,,outpatient,facility,25,UN,4.55,4.55,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIMETHYL SULFOXIDE 50 ML VIAL,2500003351,CDM,636,RC,J1212,HCPCS,6745717850,NDC,,,,inpatient,facility,50,UN,987.82,987.82,79.03,987.82,,,,,,,,,,,,,,987.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,987.82,,,percent of total billed charges,,,,,,,,,987.82,,,percent of total billed charges,,,504.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,841.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.69,,,percent of total billed charges,,,,,,,,,,,,,,,987.82,,,percent of total billed charges,,,839.65,,,percent of total billed charges,,,,,,,,,,,,,,,987.82,,,percent of total billed charges,,,524.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,987.82,,,percent of total billed charges,,,,,,,,,,,,,,,79.03,,,percent of total billed charges,,,987.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,987.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,582.02,,,percent of total billed charges,,
DIMETHYL SULFOXIDE 50 ML VIAL,2500003351,CDM,636,RC,J1212,HCPCS,6745717850,NDC,,,,outpatient,facility,50,UN,987.82,987.82,79.03,987.82,,700.46,,,percent of total billed charges,,,,,,,,,987.82,,,percent of total billed charges,,,916.61,,,fee schedule,,,867.18,,,fee schedule,,,,,,,,,867.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,987.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,987.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,987.82,,,fee schedule,,,987.82,,,percent of total billed charges,,,,,,,,,987.82,,,percent of total billed charges,,,605.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,703.82,,,percent of total billed charges,,,,,,,,,,,,,,,680.82,,,fee schedule,,,680.82,,,fee schedule,,,680.82,,,fee schedule,,,,,,,,,582.81,,,percent of total billed charges,,,548.68,,,per diem,,,987.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,987.82,,,percent of total billed charges,,,839.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,524.63,,,percent of total billed charges,,,987.82,,,percent of total billed charges,,,987.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,666.38,,,percent of total billed charges,,,799.34,,,percent of total billed charges,,,,,,,,,,,,,,,395.13,,,percent of total billed charges,,,,,,,,,987.82,,,fee schedule,,,987.82,,,fee schedule,,,,,,,,,987.82,,,percent of total billed charges,,,,,,,,,,,,,,,79.03,,,percent of total billed charges,,,987.82,,,percent of total billed charges,,,,,,,,,,,,,,,987.82,,,percent of total billed charges,,,987.82,,,percent of total billed charges,,,,,,,,,668.37,,,fee schedule,,,,,,,,,,,,,,,579.29,,,fee schedule,,,772.38,,,fee schedule,,,434.44,,,fee schedule,,,732.82,,,fee schedule,,,987.82,,,percent of total billed charges,,,987.82,,,percent of total billed charges,,,987.82,,,percent of total billed charges,,,,,,,,,692.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,493.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,582.02,,,percent of total billed charges,,
DIMETHYL SULFOXIDE 50 ML VIAL,2500003351,CDM,636,RC,J1212,HCPCS,6745717850,NDC,1832,APC,,outpatient,facility,50,UN,987.82,987.82,361.54,1073.08,,,,,,,,736.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,715.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,722.54,,,fee schedule,,,,,,,,,361.54,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,715.39,,,fee schedule,,,,,,,,,,,,,,,751.16,,,fee schedule,,,751.16,,,fee schedule,,,,,,,,,715.39,,,fee schedule,,,715.39,,,fee schedule,,,751.16,,,fee schedule,,,,,,,,,,,,,,,1073.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,715.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,686.77,,,fee schedule,,,765.47,,,fee schedule,,,751.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,715.39,,,fee schedule,,,715.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,744.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,715.39,,,fee schedule,,,,,,,,,894.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,894.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,715.39,,,fee schedule,,,715.39,,,fee schedule,,,,,,,,,,,,,,,715.39,,,fee schedule,,,,,,,,,715.39,,,fee schedule,,,736.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,715.39,,,fee schedule,,,,,,,,,,,,,,,744.01,,,fee schedule,,,715.39,,,fee schedule,,,,,,,,,715.39,,,fee schedule,,,,,,,,,715.39,,,fee schedule,,,751.16,,,fee schedule,,,,,,,,
DIMETHYL SULFOXIDE 50 ML VIAL,2500003351,CDM,636,RC,J1212,HCPCS,6745717850,NDC,439,EAPG,,outpatient,facility,50,UN,987.82,987.82,790.67,1193.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1193.91,,,fee schedule,,,790.67,,,fee schedule,,,1061.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.67,,,fee schedule,,,790.67,,,fee schedule,,,790.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,790.67,,,fee schedule,,,,,,,,,,,,,,,790.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DAPAGLIFLOZIN PROPNEDL 5MG TAB,2500003361,CDM,637,RC,310620530,NDC,,,,,,inpatient,facility,5,UN,64.05,64.05,5.12,64.05,,,,,,,,,,,,,,64.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.05,,,percent of total billed charges,,,,,,,,,64.05,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.43,,,percent of total billed charges,,,,,,,,,,,,,,,64.05,,,percent of total billed charges,,,54.44,,,percent of total billed charges,,,,,,,,,,,,,,,64.05,,,percent of total billed charges,,,34.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,64.05,,,percent of total billed charges,,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,64.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.74,,,percent of total billed charges,,
DAPAGLIFLOZIN PROPNEDL 5MG TAB,2500003361,CDM,637,RC,310620530,NDC,,,,,,outpatient,facility,5,UN,64.05,64.05,5.12,548.68,,45.42,,,percent of total billed charges,,,15.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,64.05,,,percent of total billed charges,,,40.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,45.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,45.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,64.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,23.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,64.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,64.05,,,fee schedule,,,64.05,,,percent of total billed charges,,,,,,,,,64.05,,,percent of total billed charges,,,39.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.64,,,percent of total billed charges,,,,,,,,,,,,,,,34.59,,,percent of total billed charges,,,33.31,,,percent of total billed charges,,,35.23,,,percent of total billed charges,,,,,,,,,37.79,,,percent of total billed charges,,,548.68,,,per diem,,,64.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,64.05,,,percent of total billed charges,,,54.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.02,,,percent of total billed charges,,,64.05,,,percent of total billed charges,,,64.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.21,,,percent of total billed charges,,,51.83,,,percent of total billed charges,,,,,,,,,,,,,,,25.62,,,percent of total billed charges,,,,,,,,,23.7,,,percent of total billed charges,,,23.7,,,percent of total billed charges,,,,,,,,,64.05,,,percent of total billed charges,,,64.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,64.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.12,,,percent of total billed charges,,,64.05,,,percent of total billed charges,,,,,,,,,,,,,,,64.05,,,percent of total billed charges,,,64.05,,,percent of total billed charges,,,,,,,,,59.58,,,percent of total billed charges,,,,,,,,,,,,,,,59.58,,,percent of total billed charges,,,59.58,,,percent of total billed charges,,,59.58,,,percent of total billed charges,,,48.04,,,percent of total billed charges,,,64.05,,,percent of total billed charges,,,64.05,,,percent of total billed charges,,,64.05,,,percent of total billed charges,,,,,,,,,44.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,37.74,,,percent of total billed charges,,
DAPAGLIFLOZIN PROPNEDL 5MG TAB,2500003361,CDM,637,RC,310620530,NDC,999,EAPG,,,,outpatient,facility,5,UN,64.05,64.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LACTULOSE 300ML/700ML NS ENEMA,2500003366,CDM,637,RC,121115400,NDC,,,,,,inpatient,facility,1000,UN,199.65,199.65,15.97,199.65,,,,,,,,,,,,,,199.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.65,,,percent of total billed charges,,,,,,,,,199.65,,,percent of total billed charges,,,101.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.79,,,percent of total billed charges,,,,,,,,,,,,,,,199.65,,,percent of total billed charges,,,169.7,,,percent of total billed charges,,,,,,,,,,,,,,,199.65,,,percent of total billed charges,,,106.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,199.65,,,percent of total billed charges,,,,,,,,,,,,,,,15.97,,,percent of total billed charges,,,199.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,199.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.63,,,percent of total billed charges,,
LACTULOSE 300ML/700ML NS ENEMA,2500003366,CDM,637,RC,121115400,NDC,,,,,,outpatient,facility,1000,UN,199.65,199.65,15.97,548.68,,141.57,,,percent of total billed charges,,,48.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,199.65,,,percent of total billed charges,,,125.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,140.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,140.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,199.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,73.07,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,199.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,199.65,,,fee schedule,,,199.65,,,percent of total billed charges,,,,,,,,,199.65,,,percent of total billed charges,,,122.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.25,,,percent of total billed charges,,,,,,,,,,,,,,,107.81,,,percent of total billed charges,,,103.82,,,percent of total billed charges,,,109.81,,,percent of total billed charges,,,,,,,,,117.79,,,percent of total billed charges,,,548.68,,,per diem,,,199.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,199.65,,,percent of total billed charges,,,169.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.03,,,percent of total billed charges,,,199.65,,,percent of total billed charges,,,199.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.68,,,percent of total billed charges,,,161.56,,,percent of total billed charges,,,,,,,,,,,,,,,79.86,,,percent of total billed charges,,,,,,,,,73.87,,,percent of total billed charges,,,73.87,,,percent of total billed charges,,,,,,,,,199.65,,,percent of total billed charges,,,199.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,199.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.97,,,percent of total billed charges,,,199.65,,,percent of total billed charges,,,,,,,,,,,,,,,199.65,,,percent of total billed charges,,,199.65,,,percent of total billed charges,,,,,,,,,185.71,,,percent of total billed charges,,,,,,,,,,,,,,,185.71,,,percent of total billed charges,,,185.71,,,percent of total billed charges,,,185.71,,,percent of total billed charges,,,149.74,,,percent of total billed charges,,,199.65,,,percent of total billed charges,,,199.65,,,percent of total billed charges,,,199.65,,,percent of total billed charges,,,,,,,,,139.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,117.63,,,percent of total billed charges,,
LACTULOSE 300ML/700ML NS ENEMA,2500003366,CDM,637,RC,121115400,NDC,999,EAPG,,,,outpatient,facility,1000,UN,199.65,199.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DARATUMUMAB-HYAL-FIHJ 1800MG,2500003379,CDM,636,RC,J9144,HCPCS,5789450301,NDC,,,,inpatient,facility,15,ML,31987.13,31987.13,2558.97,31987.13,,,,,,,,,,,,,,31987.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31987.13,,,percent of total billed charges,,,,,,,,,31987.13,,,percent of total billed charges,,,16332.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27243.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19192.28,,,percent of total billed charges,,,,,,,,,,,,,,,31987.13,,,percent of total billed charges,,,27189.06,,,percent of total billed charges,,,,,,,,,,,,,,,31987.13,,,percent of total billed charges,,,16988.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12794.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,31987.13,,,percent of total billed charges,,,,,,,,,,,,,,,2558.97,,,percent of total billed charges,,,31987.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31987.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18846.82,,,percent of total billed charges,,
DARATUMUMAB-HYAL-FIHJ 1800MG,2500003379,CDM,636,RC,J9144,HCPCS,5789450301,NDC,,,,outpatient,facility,15,ML,31987.13,31987.13,31.92,31987.13,,48.8,,,fee schedule,,,,,,,,,31987.13,,,percent of total billed charges,,,66.2,,,fee schedule,,,62.63,,,fee schedule,,,,,,,,,62.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,31987.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,31987.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,31987.13,,,fee schedule,,,31987.13,,,percent of total billed charges,,,,,,,,,31987.13,,,percent of total billed charges,,,19604.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22790.83,,,percent of total billed charges,,,,,,,,,,,,,,,49.05,,,fee schedule,,,49.05,,,fee schedule,,,49.05,,,fee schedule,,,,,,,,,18872.41,,,percent of total billed charges,,,548.68,,,per diem,,,31987.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,31987.13,,,percent of total billed charges,,,27189.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16988.36,,,percent of total billed charges,,,31987.13,,,percent of total billed charges,,,31987.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21578.52,,,percent of total billed charges,,,25883.99,,,percent of total billed charges,,,,,,,,,,,,,,,12794.85,,,percent of total billed charges,,,,,,,,,114.89,,,fee schedule,,,82.67,,,fee schedule,,,,,,,,,31987.13,,,percent of total billed charges,,,,,,,,,,,,,,,2558.97,,,percent of total billed charges,,,31987.13,,,percent of total billed charges,,,,,,,,,,,,,,,31987.13,,,percent of total billed charges,,,31987.13,,,percent of total billed charges,,,,,,,,,49.1,,,fee schedule,,,,,,,,,,,,,,,42.56,,,fee schedule,,,56.74,,,fee schedule,,,31.92,,,fee schedule,,,52.92,,,fee schedule,,,31987.13,,,percent of total billed charges,,,31987.13,,,percent of total billed charges,,,31987.13,,,percent of total billed charges,,,,,,,,,22426.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15993.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18846.82,,,percent of total billed charges,,
DARATUMUMAB-HYAL-FIHJ 1800MG,2500003379,CDM,636,RC,J9144,HCPCS,5789450301,NDC,9378,APC,,outpatient,facility,15,ML,31987.13,31987.13,49.33,11707.29,,,,,,,,52.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,51.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.9,,,fee schedule,,,,,,,,,11707.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,51.39,,,fee schedule,,,,,,,,,,,,,,,53.96,,,fee schedule,,,53.96,,,fee schedule,,,,,,,,,51.39,,,fee schedule,,,51.39,,,fee schedule,,,53.96,,,fee schedule,,,,,,,,,,,,,,,77.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,51.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.33,,,fee schedule,,,54.99,,,fee schedule,,,53.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.39,,,fee schedule,,,51.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,53.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,51.39,,,fee schedule,,,,,,,,,64.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,64.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,51.39,,,fee schedule,,,51.39,,,fee schedule,,,,,,,,,,,,,,,51.39,,,fee schedule,,,,,,,,,51.39,,,fee schedule,,,52.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.39,,,fee schedule,,,,,,,,,,,,,,,53.45,,,fee schedule,,,51.39,,,fee schedule,,,,,,,,,51.39,,,fee schedule,,,,,,,,,51.39,,,fee schedule,,,53.96,,,fee schedule,,,,,,,,
DARATUMUMAB-HYAL-FIHJ 1800MG,2500003379,CDM,636,RC,J9144,HCPCS,5789450301,NDC,462,EAPG,,outpatient,facility,15,ML,31987.13,31987.13,4724.8,7134.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7134.45,,,fee schedule,,,4724.8,,,fee schedule,,,6342.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4724.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4724.8,,,fee schedule,,,4724.8,,,fee schedule,,,4724.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4724.8,,,fee schedule,,,,,,,,,,,,,,,4724.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NORTHNDRNE-ETHIN ESTRADIOL TAB,2500003384,CDM,637,RC,555900942,NDC,,,,,,inpatient,facility,1,UN,4.13,4.13,0.33,4.13,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,,,,,,,4.13,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,
NORTHNDRNE-ETHIN ESTRADIOL TAB,2500003384,CDM,637,RC,555900942,NDC,,,,,,outpatient,facility,1,UN,4.13,4.13,0.33,548.68,,2.93,,,percent of total billed charges,,,1.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.13,,,percent of total billed charges,,,2.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.51,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.13,,,fee schedule,,,4.13,,,percent of total billed charges,,,,,,,,,4.13,,,percent of total billed charges,,,2.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,2.27,,,percent of total billed charges,,,,,,,,,2.44,,,percent of total billed charges,,,548.68,,,per diem,,,4.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.13,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.79,,,percent of total billed charges,,,3.34,,,percent of total billed charges,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,1.53,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,,,,,,,4.13,,,percent of total billed charges,,,4.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.33,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,,,,,,,3.84,,,percent of total billed charges,,,,,,,,,,,,,,,3.84,,,percent of total billed charges,,,3.84,,,percent of total billed charges,,,3.84,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.43,,,percent of total billed charges,,
NORTHNDRNE-ETHIN ESTRADIOL TAB,2500003384,CDM,637,RC,555900942,NDC,999,EAPG,,,,outpatient,facility,1,UN,4.13,4.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 4  PATCH,2500003385,CDM,637,RC,536120215,NDC,,,,,,inpatient,facility,1,UN,4.12,4.12,0.33,4.12,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,4.12,,,percent of total billed charges,,,2.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,
LIDOCAINE 4  PATCH,2500003385,CDM,637,RC,536120215,NDC,,,,,,outpatient,facility,1,UN,4.12,4.12,0.33,548.68,,2.92,,,percent of total billed charges,,,1.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.12,,,percent of total billed charges,,,2.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.51,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.12,,,fee schedule,,,4.12,,,percent of total billed charges,,,,,,,,,4.12,,,percent of total billed charges,,,2.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.27,,,percent of total billed charges,,,,,,,,,2.43,,,percent of total billed charges,,,548.68,,,per diem,,,4.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.12,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.78,,,percent of total billed charges,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,4.12,,,percent of total billed charges,,,4.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.33,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.43,,,percent of total billed charges,,
LIDOCAINE 4  PATCH,2500003385,CDM,637,RC,536120215,NDC,999,EAPG,,,,outpatient,facility,1,UN,4.12,4.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRASTUZUMAB-QYYP 10 MG INJ,2500003386,CDM,636,RC,Q5116,HCPCS,69030501,NDC,,,,inpatient,facility,10,UN,266.44,266.44,21.32,266.44,,,,,,,,,,,,,,266.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.44,,,percent of total billed charges,,,,,,,,,266.44,,,percent of total billed charges,,,136.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.86,,,percent of total billed charges,,,,,,,,,,,,,,,266.44,,,percent of total billed charges,,,226.47,,,percent of total billed charges,,,,,,,,,,,,,,,266.44,,,percent of total billed charges,,,141.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,266.44,,,percent of total billed charges,,,,,,,,,,,,,,,21.32,,,percent of total billed charges,,,266.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.99,,,percent of total billed charges,,
TRASTUZUMAB-QYYP 10 MG INJ,2500003386,CDM,636,RC,Q5116,HCPCS,69030501,NDC,,,,outpatient,facility,10,UN,266.44,266.44,12.77,548.68,,12.77,,,fee schedule,,,,,,,,,266.44,,,percent of total billed charges,,,16.41,,,fee schedule,,,15.52,,,fee schedule,,,,,,,,,15.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,266.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,266.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,266.44,,,fee schedule,,,266.44,,,percent of total billed charges,,,,,,,,,266.44,,,percent of total billed charges,,,163.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.84,,,percent of total billed charges,,,,,,,,,,,,,,,16.37,,,fee schedule,,,16.37,,,fee schedule,,,16.37,,,fee schedule,,,,,,,,,157.2,,,percent of total billed charges,,,548.68,,,per diem,,,266.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,266.44,,,percent of total billed charges,,,226.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,141.51,,,percent of total billed charges,,,266.44,,,percent of total billed charges,,,266.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.74,,,percent of total billed charges,,,215.6,,,percent of total billed charges,,,,,,,,,,,,,,,106.58,,,percent of total billed charges,,,,,,,,,98.3,,,fee schedule,,,70.74,,,fee schedule,,,,,,,,,266.44,,,percent of total billed charges,,,,,,,,,,,,,,,21.32,,,percent of total billed charges,,,266.44,,,percent of total billed charges,,,,,,,,,,,,,,,266.44,,,percent of total billed charges,,,266.44,,,percent of total billed charges,,,,,,,,,42.01,,,fee schedule,,,,,,,,,,,,,,,36.41,,,fee schedule,,,48.55,,,fee schedule,,,27.31,,,fee schedule,,,13.12,,,fee schedule,,,266.44,,,percent of total billed charges,,,266.44,,,percent of total billed charges,,,266.44,,,percent of total billed charges,,,,,,,,,186.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,156.99,,,percent of total billed charges,,
TRASTUZUMAB-QYYP 10 MG INJ,2500003386,CDM,636,RC,Q5116,HCPCS,69030501,NDC,9350,APC,,outpatient,facility,10,UN,266.44,266.44,18.21,97.52,,,,,,,,19.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,18.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.16,,,fee schedule,,,,,,,,,97.52,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,18.97,,,fee schedule,,,,,,,,,,,,,,,19.92,,,fee schedule,,,19.92,,,fee schedule,,,,,,,,,18.97,,,fee schedule,,,18.97,,,fee schedule,,,19.92,,,fee schedule,,,,,,,,,,,,,,,28.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,18.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.21,,,fee schedule,,,20.3,,,fee schedule,,,19.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.97,,,fee schedule,,,18.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,19.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,18.97,,,fee schedule,,,,,,,,,23.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,18.97,,,fee schedule,,,18.97,,,fee schedule,,,,,,,,,,,,,,,18.97,,,fee schedule,,,,,,,,,18.97,,,fee schedule,,,19.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.97,,,fee schedule,,,,,,,,,,,,,,,19.73,,,fee schedule,,,18.97,,,fee schedule,,,,,,,,,18.97,,,fee schedule,,,,,,,,,18.97,,,fee schedule,,,19.92,,,fee schedule,,,,,,,,
TRASTUZUMAB-QYYP 10 MG INJ,2500003386,CDM,636,RC,Q5116,HCPCS,69030501,NDC,461,EAPG,,outpatient,facility,10,UN,266.44,266.44,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREDNISOLONE 15MG,2500003412,CDM,636,RC,J7510,HCPCS,5038304224,NDC,,,,inpatient,facility,5,UN,7.95,7.95,0.64,7.95,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,7.95,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,6.76,,,percent of total billed charges,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,
PREDNISOLONE 15MG,2500003412,CDM,636,RC,J7510,HCPCS,5038304224,NDC,,,,outpatient,facility,5,UN,7.95,7.95,0.25,548.68,,5.64,,,percent of total billed charges,,,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.95,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.95,,,fee schedule,,,7.95,,,percent of total billed charges,,,,,,,,,7.95,,,percent of total billed charges,,,4.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,4.69,,,percent of total billed charges,,,548.68,,,per diem,,,7.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.95,,,percent of total billed charges,,,6.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.36,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,3.18,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7.95,,,percent of total billed charges,,,7.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.64,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.25,,,fee schedule,,,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,5.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.68,,,percent of total billed charges,,
PREDNISOLONE 15MG,2500003412,CDM,636,RC,J7510,HCPCS,5038304224,NDC,496,EAPG,,outpatient,facility,5,UN,7.95,7.95,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMIVANTAMAB-VMJW 350MG/7ML INJ,2500003427,CDM,636,RC,J9061,HCPCS,5789450101,NDC,,,,inpatient,facility,7,ML,12032.95,12032.95,962.64,12032.95,,,,,,,,,,,,,,12032.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12032.95,,,percent of total billed charges,,,,,,,,,12032.95,,,percent of total billed charges,,,6144.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10248.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7219.77,,,percent of total billed charges,,,,,,,,,,,,,,,12032.95,,,percent of total billed charges,,,10228.01,,,percent of total billed charges,,,,,,,,,,,,,,,12032.95,,,percent of total billed charges,,,6390.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4813.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12032.95,,,percent of total billed charges,,,,,,,,,,,,,,,962.64,,,percent of total billed charges,,,12032.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12032.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7089.81,,,percent of total billed charges,,
AMIVANTAMAB-VMJW 350MG/7ML INJ,2500003427,CDM,636,RC,J9061,HCPCS,5789450101,NDC,,,,outpatient,facility,7,ML,12032.95,12032.95,12.9,12032.95,,19.99,,,fee schedule,,,,,,,,,12032.95,,,percent of total billed charges,,,26.7,,,fee schedule,,,25.26,,,fee schedule,,,,,,,,,25.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,12032.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12032.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,12032.95,,,fee schedule,,,12032.95,,,percent of total billed charges,,,,,,,,,12032.95,,,percent of total billed charges,,,7375,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8573.48,,,percent of total billed charges,,,,,,,,,,,,,,,19.98,,,fee schedule,,,19.98,,,fee schedule,,,19.98,,,fee schedule,,,,,,,,,7099.44,,,percent of total billed charges,,,548.68,,,per diem,,,12032.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12032.95,,,percent of total billed charges,,,10228.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6390.7,,,percent of total billed charges,,,12032.95,,,percent of total billed charges,,,12032.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8117.43,,,percent of total billed charges,,,9737.06,,,percent of total billed charges,,,,,,,,,,,,,,,4813.18,,,percent of total billed charges,,,,,,,,,46.44,,,fee schedule,,,33.42,,,fee schedule,,,,,,,,,12032.95,,,percent of total billed charges,,,,,,,,,,,,,,,962.64,,,percent of total billed charges,,,12032.95,,,percent of total billed charges,,,,,,,,,,,,,,,12032.95,,,percent of total billed charges,,,12032.95,,,percent of total billed charges,,,,,,,,,19.85,,,fee schedule,,,,,,,,,,,,,,,17.2,,,fee schedule,,,22.93,,,fee schedule,,,12.9,,,fee schedule,,,21.34,,,fee schedule,,,12032.95,,,percent of total billed charges,,,12032.95,,,percent of total billed charges,,,12032.95,,,percent of total billed charges,,,,,,,,,8436.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6016.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7089.81,,,percent of total billed charges,,
AMIVANTAMAB-VMJW 350MG/7ML INJ,2500003427,CDM,636,RC,J9061,HCPCS,5789450101,NDC,9432,APC,,outpatient,facility,7,ML,12032.95,12032.95,20.7,4404.06,,,,,,,,22.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,21.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.78,,,fee schedule,,,,,,,,,4404.06,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,21.56,,,fee schedule,,,,,,,,,,,,,,,22.64,,,fee schedule,,,22.64,,,fee schedule,,,,,,,,,21.56,,,fee schedule,,,21.56,,,fee schedule,,,22.64,,,fee schedule,,,,,,,,,,,,,,,32.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,21.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.7,,,fee schedule,,,23.07,,,fee schedule,,,22.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.56,,,fee schedule,,,21.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,22.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,21.56,,,fee schedule,,,,,,,,,26.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,21.56,,,fee schedule,,,21.56,,,fee schedule,,,,,,,,,,,,,,,21.56,,,fee schedule,,,,,,,,,21.56,,,fee schedule,,,22.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.56,,,fee schedule,,,,,,,,,,,,,,,22.42,,,fee schedule,,,21.56,,,fee schedule,,,,,,,,,21.56,,,fee schedule,,,,,,,,,21.56,,,fee schedule,,,22.64,,,fee schedule,,,,,,,,
AMIVANTAMAB-VMJW 350MG/7ML INJ,2500003427,CDM,636,RC,J9061,HCPCS,5789450101,NDC,463,EAPG,,outpatient,facility,7,ML,12032.95,12032.95,7053.67,10651.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10651.04,,,fee schedule,,,7053.67,,,fee schedule,,,9468.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUTEROL SULF INH SOL.083 3ML,2500003440,CDM,637,RC,J7613,HCPCS,487950101,NDC,,,,inpatient,facility,3,UN,2.64,2.64,0.21,2.64,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,
ALBUTEROL SULF INH SOL.083 3ML,2500003440,CDM,637,RC,J7613,HCPCS,487950101,NDC,,,,outpatient,facility,3,UN,2.64,2.64,0.03,548.68,,1.87,,,percent of total billed charges,,,0.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.64,,,percent of total billed charges,,,0.06,,,fee schedule,,,0.06,,,fee schedule,,,,,,,,,0.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.97,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.07,,,fee schedule,,,2.64,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,fee schedule,,,0.04,,,fee schedule,,,0.04,,,fee schedule,,,,,,,,,1.56,,,percent of total billed charges,,,548.68,,,per diem,,,2.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.64,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,0.1,,,fee schedule,,,0.07,,,fee schedule,,,,,,,,,2.64,,,percent of total billed charges,,,2.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,0.04,,,fee schedule,,,,,,,,,,,,,,,0.04,,,fee schedule,,,0.05,,,fee schedule,,,0.03,,,fee schedule,,,0.04,,,fee schedule,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.56,,,percent of total billed charges,,
ALBUTEROL SULF INH SOL.083 3ML,2500003440,CDM,637,RC,J7613,HCPCS,487950101,NDC,999,EAPG,,outpatient,facility,3,UN,2.64,2.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIRMATRLVIR/RITNVIR 150-100 DP,2500003452,CDM,637,RC,69532130,NDC,,,,,,inpatient,facility,1,UN,212.42,212.42,16.99,212.42,,,,,,,,,,,,,,212.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,212.42,,,percent of total billed charges,,,,,,,,,212.42,,,percent of total billed charges,,,108.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.45,,,percent of total billed charges,,,,,,,,,,,,,,,212.42,,,percent of total billed charges,,,180.56,,,percent of total billed charges,,,,,,,,,,,,,,,212.42,,,percent of total billed charges,,,112.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,212.42,,,percent of total billed charges,,,,,,,,,,,,,,,16.99,,,percent of total billed charges,,,212.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,212.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.16,,,percent of total billed charges,,
NIRMATRLVIR/RITNVIR 150-100 DP,2500003452,CDM,637,RC,69532130,NDC,,,,,,outpatient,facility,1,UN,212.42,212.42,16.99,548.68,,150.63,,,percent of total billed charges,,,51.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,212.42,,,percent of total billed charges,,,133.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,149.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,149.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,212.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,77.75,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,212.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,212.42,,,fee schedule,,,212.42,,,percent of total billed charges,,,,,,,,,212.42,,,percent of total billed charges,,,130.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.35,,,percent of total billed charges,,,,,,,,,,,,,,,114.71,,,percent of total billed charges,,,110.46,,,percent of total billed charges,,,116.83,,,percent of total billed charges,,,,,,,,,125.33,,,percent of total billed charges,,,548.68,,,per diem,,,212.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,212.42,,,percent of total billed charges,,,180.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.82,,,percent of total billed charges,,,212.42,,,percent of total billed charges,,,212.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.3,,,percent of total billed charges,,,171.89,,,percent of total billed charges,,,,,,,,,,,,,,,84.97,,,percent of total billed charges,,,,,,,,,78.6,,,percent of total billed charges,,,78.6,,,percent of total billed charges,,,,,,,,,212.42,,,percent of total billed charges,,,212.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,212.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.99,,,percent of total billed charges,,,212.42,,,percent of total billed charges,,,,,,,,,,,,,,,212.42,,,percent of total billed charges,,,212.42,,,percent of total billed charges,,,,,,,,,197.59,,,percent of total billed charges,,,,,,,,,,,,,,,197.59,,,percent of total billed charges,,,197.59,,,percent of total billed charges,,,197.59,,,percent of total billed charges,,,159.31,,,percent of total billed charges,,,212.42,,,percent of total billed charges,,,212.42,,,percent of total billed charges,,,212.42,,,percent of total billed charges,,,,,,,,,148.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,125.16,,,percent of total billed charges,,
NIRMATRLVIR/RITNVIR 150-100 DP,2500003452,CDM,637,RC,69532130,NDC,999,EAPG,,,,outpatient,facility,1,UN,212.42,212.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALPHA-1-PROT (GLASSIA) 1 MG,2500003456,CDM,636,RC,J0257,HCPCS,944288401,NDC,,,,inpatient,facility,1,UN,1.74,1.74,0.14,1.74,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,1.74,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,
ALPHA-1-PROT (GLASSIA) 1 MG,2500003456,CDM,636,RC,J0257,HCPCS,944288401,NDC,,,,outpatient,facility,1,UN,1.74,1.74,0.14,548.68,,1.23,,,percent of total billed charges,,,,,,,,,1.74,,,percent of total billed charges,,,7,,,fee schedule,,,6.62,,,fee schedule,,,,,,,,,6.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,1.74,,,fee schedule,,,1.74,,,percent of total billed charges,,,,,,,,,1.74,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,1.74,,,fee schedule,,,1.74,,,fee schedule,,,1.74,,,fee schedule,,,,,,,,,1.03,,,percent of total billed charges,,,548.68,,,per diem,,,1.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.74,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,,,,1.74,,,fee schedule,,,1.74,,,fee schedule,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,1.74,,,fee schedule,,,,,,,,,,,,,,,1.74,,,fee schedule,,,1.74,,,fee schedule,,,1.74,,,fee schedule,,,1.74,,,fee schedule,,,1.74,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.03,,,percent of total billed charges,,
ALPHA-1-PROT (GLASSIA) 1 MG,2500003456,CDM,636,RC,J0257,HCPCS,944288401,NDC,1415,APC,,outpatient,facility,1,UN,1.74,1.74,0.64,8.26,,,,,,,,5.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,5.51,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.57,,,fee schedule,,,,,,,,,0.64,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,fee schedule,,,,,,,,,,,,,,,5.79,,,fee schedule,,,5.79,,,fee schedule,,,,,,,,,5.51,,,fee schedule,,,5.51,,,fee schedule,,,5.79,,,fee schedule,,,,,,,,,,,,,,,8.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5.51,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.29,,,fee schedule,,,5.9,,,fee schedule,,,5.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,fee schedule,,,5.51,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,fee schedule,,,,,,,,,6.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,5.51,,,fee schedule,,,5.51,,,fee schedule,,,,,,,,,,,,,,,5.51,,,fee schedule,,,,,,,,,5.51,,,fee schedule,,,5.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,fee schedule,,,,,,,,,,,,,,,5.73,,,fee schedule,,,5.51,,,fee schedule,,,,,,,,,5.51,,,fee schedule,,,,,,,,,5.51,,,fee schedule,,,5.79,,,fee schedule,,,,,,,,
ALPHA-1-PROT (GLASSIA) 1 MG,2500003456,CDM,636,RC,J0257,HCPCS,944288401,NDC,460,EAPG,,outpatient,facility,1,UN,1.74,1.74,1604.23,2422.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2422.39,,,fee schedule,,,1604.23,,,fee schedule,,,2153.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POLATUZUMAB VEDOTIN-PIIQ 30 MG,2500003460,CDM,636,RC,J9309,HCPCS,5024210301,NDC,,,,inpatient,facility,30,UN,12777.63,12777.63,1022.21,12777.63,,,,,,,,,,,,,,12777.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12777.63,,,percent of total billed charges,,,,,,,,,12777.63,,,percent of total billed charges,,,6524.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10882.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7666.58,,,percent of total billed charges,,,,,,,,,,,,,,,12777.63,,,percent of total billed charges,,,10860.99,,,percent of total billed charges,,,,,,,,,,,,,,,12777.63,,,percent of total billed charges,,,6786.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5111.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12777.63,,,percent of total billed charges,,,,,,,,,,,,,,,1022.21,,,percent of total billed charges,,,12777.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12777.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7528.58,,,percent of total billed charges,,
POLATUZUMAB VEDOTIN-PIIQ 30 MG,2500003460,CDM,636,RC,J9309,HCPCS,5024210301,NDC,,,,outpatient,facility,30,UN,12777.63,12777.63,80.61,12777.63,,124.03,,,fee schedule,,,,,,,,,12777.63,,,percent of total billed charges,,,168.69,,,fee schedule,,,159.59,,,fee schedule,,,,,,,,,159.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,12777.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12777.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,12777.63,,,fee schedule,,,12777.63,,,percent of total billed charges,,,,,,,,,12777.63,,,percent of total billed charges,,,7831.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9104.06,,,percent of total billed charges,,,,,,,,,,,,,,,124.29,,,fee schedule,,,124.29,,,fee schedule,,,124.29,,,fee schedule,,,,,,,,,7538.8,,,percent of total billed charges,,,548.68,,,per diem,,,12777.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12777.63,,,percent of total billed charges,,,10860.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6786.2,,,percent of total billed charges,,,12777.63,,,percent of total billed charges,,,12777.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8619.79,,,percent of total billed charges,,,10339.66,,,percent of total billed charges,,,,,,,,,,,,,,,5111.05,,,percent of total billed charges,,,,,,,,,290.2,,,fee schedule,,,208.82,,,fee schedule,,,,,,,,,12777.63,,,percent of total billed charges,,,,,,,,,,,,,,,1022.21,,,percent of total billed charges,,,12777.63,,,percent of total billed charges,,,,,,,,,,,,,,,12777.63,,,percent of total billed charges,,,12777.63,,,percent of total billed charges,,,,,,,,,124.02,,,fee schedule,,,,,,,,,,,,,,,107.48,,,fee schedule,,,143.31,,,fee schedule,,,80.61,,,fee schedule,,,134.86,,,fee schedule,,,12777.63,,,percent of total billed charges,,,12777.63,,,percent of total billed charges,,,12777.63,,,percent of total billed charges,,,,,,,,,8958.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6388.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7528.58,,,percent of total billed charges,,
POLATUZUMAB VEDOTIN-PIIQ 30 MG,2500003460,CDM,636,RC,J9309,HCPCS,5024210301,NDC,9331,APC,,outpatient,facility,30,UN,12777.63,12777.63,127.6,4676.61,,,,,,,,136.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,132.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.25,,,fee schedule,,,,,,,,,4676.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,132.92,,,fee schedule,,,,,,,,,,,,,,,139.57,,,fee schedule,,,139.57,,,fee schedule,,,,,,,,,132.92,,,fee schedule,,,132.92,,,fee schedule,,,139.57,,,fee schedule,,,,,,,,,,,,,,,199.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,132.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.6,,,fee schedule,,,142.22,,,fee schedule,,,139.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.92,,,fee schedule,,,132.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,138.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,132.92,,,fee schedule,,,,,,,,,166.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,166.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,132.92,,,fee schedule,,,132.92,,,fee schedule,,,,,,,,,,,,,,,132.92,,,fee schedule,,,,,,,,,132.92,,,fee schedule,,,136.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.92,,,fee schedule,,,,,,,,,,,,,,,138.24,,,fee schedule,,,132.92,,,fee schedule,,,,,,,,,132.92,,,fee schedule,,,,,,,,,132.92,,,fee schedule,,,139.57,,,fee schedule,,,,,,,,
POLATUZUMAB VEDOTIN-PIIQ 30 MG,2500003460,CDM,636,RC,J9309,HCPCS,5024210301,NDC,464,EAPG,,outpatient,facility,30,UN,12777.63,12777.63,8990.76,13576.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13576.05,,,fee schedule,,,8990.76,,,fee schedule,,,12069.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8990.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8990.76,,,fee schedule,,,8990.76,,,fee schedule,,,8990.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,8990.76,,,fee schedule,,,,,,,,,,,,,,,8990.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POLATUZMAB VEDOTIN-PIIQ 140MG,2500003461,CDM,636,RC,J9309,HCPCS,5024210501,NDC,,,,inpatient,facility,140,UN,59628.79,59628.79,4770.3,59628.79,,,,,,,,,,,,,,59628.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59628.79,,,percent of total billed charges,,,,,,,,,59628.79,,,percent of total billed charges,,,30446.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50785.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35777.27,,,percent of total billed charges,,,,,,,,,,,,,,,59628.79,,,percent of total billed charges,,,50684.47,,,percent of total billed charges,,,,,,,,,,,,,,,59628.79,,,percent of total billed charges,,,31668.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23851.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,59628.79,,,percent of total billed charges,,,,,,,,,,,,,,,4770.3,,,percent of total billed charges,,,59628.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59628.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35133.28,,,percent of total billed charges,,
POLATUZMAB VEDOTIN-PIIQ 140MG,2500003461,CDM,636,RC,J9309,HCPCS,5024210501,NDC,,,,outpatient,facility,140,UN,59628.79,59628.79,80.61,59628.79,,124.03,,,fee schedule,,,,,,,,,59628.79,,,percent of total billed charges,,,168.69,,,fee schedule,,,159.59,,,fee schedule,,,,,,,,,159.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,59628.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,59628.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,59628.79,,,fee schedule,,,59628.79,,,percent of total billed charges,,,,,,,,,59628.79,,,percent of total billed charges,,,36546.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42485.51,,,percent of total billed charges,,,,,,,,,,,,,,,124.29,,,fee schedule,,,124.29,,,fee schedule,,,124.29,,,fee schedule,,,,,,,,,35180.99,,,percent of total billed charges,,,548.68,,,per diem,,,59628.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,59628.79,,,percent of total billed charges,,,50684.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31668.85,,,percent of total billed charges,,,59628.79,,,percent of total billed charges,,,59628.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40225.58,,,percent of total billed charges,,,48251.62,,,percent of total billed charges,,,,,,,,,,,,,,,23851.52,,,percent of total billed charges,,,,,,,,,290.2,,,fee schedule,,,208.82,,,fee schedule,,,,,,,,,59628.79,,,percent of total billed charges,,,,,,,,,,,,,,,4770.3,,,percent of total billed charges,,,59628.79,,,percent of total billed charges,,,,,,,,,,,,,,,59628.79,,,percent of total billed charges,,,59628.79,,,percent of total billed charges,,,,,,,,,124.02,,,fee schedule,,,,,,,,,,,,,,,107.48,,,fee schedule,,,143.31,,,fee schedule,,,80.61,,,fee schedule,,,134.86,,,fee schedule,,,59628.79,,,percent of total billed charges,,,59628.79,,,percent of total billed charges,,,59628.79,,,percent of total billed charges,,,,,,,,,41805.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29814.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,35133.28,,,percent of total billed charges,,
POLATUZMAB VEDOTIN-PIIQ 140MG,2500003461,CDM,636,RC,J9309,HCPCS,5024210501,NDC,9331,APC,,outpatient,facility,140,UN,59628.79,59628.79,127.6,21824.14,,,,,,,,136.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,132.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.25,,,fee schedule,,,,,,,,,21824.14,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,132.92,,,fee schedule,,,,,,,,,,,,,,,139.57,,,fee schedule,,,139.57,,,fee schedule,,,,,,,,,132.92,,,fee schedule,,,132.92,,,fee schedule,,,139.57,,,fee schedule,,,,,,,,,,,,,,,199.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,132.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.6,,,fee schedule,,,142.22,,,fee schedule,,,139.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.92,,,fee schedule,,,132.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,138.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,132.92,,,fee schedule,,,,,,,,,166.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,166.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,132.92,,,fee schedule,,,132.92,,,fee schedule,,,,,,,,,,,,,,,132.92,,,fee schedule,,,,,,,,,132.92,,,fee schedule,,,136.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.92,,,fee schedule,,,,,,,,,,,,,,,138.24,,,fee schedule,,,132.92,,,fee schedule,,,,,,,,,132.92,,,fee schedule,,,,,,,,,132.92,,,fee schedule,,,139.57,,,fee schedule,,,,,,,,
POLATUZMAB VEDOTIN-PIIQ 140MG,2500003461,CDM,636,RC,J9309,HCPCS,5024210501,NDC,464,EAPG,,outpatient,facility,140,UN,59628.79,59628.79,11338.65,17121.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17121.36,,,fee schedule,,,11338.65,,,fee schedule,,,15221.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11338.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11338.65,,,fee schedule,,,11338.65,,,fee schedule,,,11338.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,11338.65,,,fee schedule,,,,,,,,,,,,,,,11338.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENOL 1.4  SPRAY 20 ML BTL,2500003465,CDM,637,RC,7811269480,NDC,,,,,,inpatient,facility,20,UN,6.12,6.12,0.49,6.12,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,,,,,,,6.12,,,percent of total billed charges,,,3.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.67,,,percent of total billed charges,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,5.2,,,percent of total billed charges,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,3.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.61,,,percent of total billed charges,,
PHENOL 1.4  SPRAY 20 ML BTL,2500003465,CDM,637,RC,7811269480,NDC,,,,,,outpatient,facility,20,UN,6.12,6.12,0.49,548.68,,4.34,,,percent of total billed charges,,,1.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.12,,,percent of total billed charges,,,3.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.24,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.12,,,fee schedule,,,6.12,,,percent of total billed charges,,,,,,,,,6.12,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.36,,,percent of total billed charges,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,3.18,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,3.61,,,percent of total billed charges,,,548.68,,,per diem,,,6.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.12,,,percent of total billed charges,,,5.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.25,,,percent of total billed charges,,,6.12,,,percent of total billed charges,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,,,,,,,2.26,,,percent of total billed charges,,,2.26,,,percent of total billed charges,,,,,,,,,6.12,,,percent of total billed charges,,,6.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.49,,,percent of total billed charges,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,6.12,,,percent of total billed charges,,,,,,,,,5.69,,,percent of total billed charges,,,,,,,,,,,,,,,5.69,,,percent of total billed charges,,,5.69,,,percent of total billed charges,,,5.69,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,6.12,,,percent of total billed charges,,,6.12,,,percent of total billed charges,,,6.12,,,percent of total billed charges,,,,,,,,,4.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.61,,,percent of total billed charges,,
PHENOL 1.4  SPRAY 20 ML BTL,2500003465,CDM,637,RC,7811269480,NDC,999,EAPG,,,,outpatient,facility,20,UN,6.12,6.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRN 10000MGC/10ML SYR,2500003483,CDM,637,RC,J2371,HCPCS,6937495710,NDC,,,,inpatient,facility,10,UN,19.8,19.8,1.58,19.8,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,19.8,,,percent of total billed charges,,,10.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,16.83,,,percent of total billed charges,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,10.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.67,,,percent of total billed charges,,
PHENYLEPHRN 10000MGC/10ML SYR,2500003483,CDM,637,RC,J2371,HCPCS,6937495710,NDC,,,,outpatient,facility,10,UN,19.8,19.8,1.58,548.68,,14.04,,,percent of total billed charges,,,4.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,19.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,19.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,19.8,,,fee schedule,,,19.8,,,percent of total billed charges,,,,,,,,,19.8,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,11.68,,,percent of total billed charges,,,548.68,,,per diem,,,19.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,19.8,,,percent of total billed charges,,,16.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.52,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.36,,,percent of total billed charges,,,16.02,,,percent of total billed charges,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,19.8,,,percent of total billed charges,,,19.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.58,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,14.85,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,13.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.67,,,percent of total billed charges,,
PHENYLEPHRN 10000MGC/10ML SYR,2500003483,CDM,637,RC,J2371,HCPCS,6937495710,NDC,999,EAPG,,outpatient,facility,10,UN,19.8,19.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OFLOXACIN 0.3 OPH SOL 1ML 20DR,2500003487,CDM,637,RC,6498051505,NDC,,,,,,inpatient,facility,1,UN,46.43,46.43,3.71,46.43,,,,,,,,,,,,,,46.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.43,,,percent of total billed charges,,,,,,,,,46.43,,,percent of total billed charges,,,23.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.86,,,percent of total billed charges,,,,,,,,,,,,,,,46.43,,,percent of total billed charges,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,46.43,,,percent of total billed charges,,,24.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,46.43,,,percent of total billed charges,,,,,,,,,,,,,,,3.71,,,percent of total billed charges,,,46.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.36,,,percent of total billed charges,,
OFLOXACIN 0.3 OPH SOL 1ML 20DR,2500003487,CDM,637,RC,6498051505,NDC,,,,,,outpatient,facility,1,UN,46.43,46.43,3.71,548.68,,32.92,,,percent of total billed charges,,,11.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,46.43,,,percent of total billed charges,,,29.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,32.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,32.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,46.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,16.99,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,46.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,46.43,,,fee schedule,,,46.43,,,percent of total billed charges,,,,,,,,,46.43,,,percent of total billed charges,,,28.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.08,,,percent of total billed charges,,,,,,,,,,,,,,,25.07,,,percent of total billed charges,,,24.14,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,27.39,,,percent of total billed charges,,,548.68,,,per diem,,,46.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,46.43,,,percent of total billed charges,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.66,,,percent of total billed charges,,,46.43,,,percent of total billed charges,,,46.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,37.57,,,percent of total billed charges,,,,,,,,,,,,,,,18.57,,,percent of total billed charges,,,,,,,,,17.18,,,percent of total billed charges,,,17.18,,,percent of total billed charges,,,,,,,,,46.43,,,percent of total billed charges,,,46.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.71,,,percent of total billed charges,,,46.43,,,percent of total billed charges,,,,,,,,,,,,,,,46.43,,,percent of total billed charges,,,46.43,,,percent of total billed charges,,,,,,,,,43.19,,,percent of total billed charges,,,,,,,,,,,,,,,43.19,,,percent of total billed charges,,,43.19,,,percent of total billed charges,,,43.19,,,percent of total billed charges,,,34.82,,,percent of total billed charges,,,46.43,,,percent of total billed charges,,,46.43,,,percent of total billed charges,,,46.43,,,percent of total billed charges,,,,,,,,,32.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,27.36,,,percent of total billed charges,,
OFLOXACIN 0.3 OPH SOL 1ML 20DR,2500003487,CDM,637,RC,6498051505,NDC,999,EAPG,,,,outpatient,facility,1,UN,46.43,46.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IPRATROPIUM .02  NEB 2.5 ML,2500003490,CDM,637,RC,J7644,HCPCS,487980101,NDC,,,,inpatient,facility,2.5,UN,1.19,1.19,0.1,1.19,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,1.19,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,
IPRATROPIUM .02  NEB 2.5 ML,2500003490,CDM,637,RC,J7644,HCPCS,487980101,NDC,,,,outpatient,facility,2.5,UN,1.19,1.19,0.1,548.68,,0.84,,,percent of total billed charges,,,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.19,,,percent of total billed charges,,,0.49,,,fee schedule,,,0.47,,,fee schedule,,,,,,,,,0.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.3,,,fee schedule,,,0.36,,,fee schedule,,,1.19,,,percent of total billed charges,,,,,,,,,1.19,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,fee schedule,,,0.32,,,fee schedule,,,0.32,,,fee schedule,,,,,,,,,0.7,,,percent of total billed charges,,,548.68,,,per diem,,,1.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.19,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,0.52,,,fee schedule,,,0.37,,,fee schedule,,,,,,,,,1.19,,,percent of total billed charges,,,1.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,0.22,,,fee schedule,,,,,,,,,,,,,,,0.19,,,fee schedule,,,0.25,,,fee schedule,,,0.14,,,fee schedule,,,0.39,,,fee schedule,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.7,,,percent of total billed charges,,
IPRATROPIUM .02  NEB 2.5 ML,2500003490,CDM,637,RC,J7644,HCPCS,487980101,NDC,496,EAPG,,outpatient,facility,2.5,UN,1.19,1.19,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IRON SUCROSE INJ 200MG,2500003496,CDM,636,RC,J1756,HCPCS,517231005,NDC,,,,inpatient,facility,10,ML,404.02,404.02,32.32,404.02,,,,,,,,,,,,,,404.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.02,,,percent of total billed charges,,,,,,,,,404.02,,,percent of total billed charges,,,206.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.41,,,percent of total billed charges,,,,,,,,,,,,,,,404.02,,,percent of total billed charges,,,343.42,,,percent of total billed charges,,,,,,,,,,,,,,,404.02,,,percent of total billed charges,,,214.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,404.02,,,percent of total billed charges,,,,,,,,,,,,,,,32.32,,,percent of total billed charges,,,404.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,404.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.05,,,percent of total billed charges,,
IRON SUCROSE INJ 200MG,2500003496,CDM,636,RC,J1756,HCPCS,517231005,NDC,,,,outpatient,facility,10,ML,404.02,404.02,0.24,548.68,,286.49,,,percent of total billed charges,,,98.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,404.02,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,404.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,147.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,404.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,404.02,,,fee schedule,,,404.02,,,percent of total billed charges,,,,,,,,,404.02,,,percent of total billed charges,,,247.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,238.37,,,percent of total billed charges,,,548.68,,,per diem,,,404.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,404.02,,,percent of total billed charges,,,343.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,214.58,,,percent of total billed charges,,,404.02,,,percent of total billed charges,,,404.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.55,,,percent of total billed charges,,,326.93,,,percent of total billed charges,,,,,,,,,,,,,,,161.61,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,404.02,,,percent of total billed charges,,,404.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,404.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,32.32,,,percent of total billed charges,,,404.02,,,percent of total billed charges,,,,,,,,,,,,,,,404.02,,,percent of total billed charges,,,404.02,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.24,,,fee schedule,,,404.02,,,percent of total billed charges,,,404.02,,,percent of total billed charges,,,404.02,,,percent of total billed charges,,,,,,,,,283.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,238.05,,,percent of total billed charges,,
IRON SUCROSE INJ 200MG,2500003496,CDM,636,RC,J1756,HCPCS,517231005,NDC,435,EAPG,,outpatient,facility,10,ML,404.02,404.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METFORMIN 1000MG ER.24H,2500003498,CDM,637,RC,5074263460,NDC,,,,,,inpatient,facility,1000,UN,103.62,103.62,8.29,103.62,,,,,,,,,,,,,,103.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.62,,,percent of total billed charges,,,,,,,,,103.62,,,percent of total billed charges,,,52.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.17,,,percent of total billed charges,,,,,,,,,,,,,,,103.62,,,percent of total billed charges,,,88.08,,,percent of total billed charges,,,,,,,,,,,,,,,103.62,,,percent of total billed charges,,,55.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,103.62,,,percent of total billed charges,,,,,,,,,,,,,,,8.29,,,percent of total billed charges,,,103.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.05,,,percent of total billed charges,,
METFORMIN 1000MG ER.24H,2500003498,CDM,637,RC,5074263460,NDC,,,,,,outpatient,facility,1000,UN,103.62,103.62,8.29,548.68,,73.48,,,percent of total billed charges,,,25.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,103.62,,,percent of total billed charges,,,64.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,72.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,72.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,103.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,37.92,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,103.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,103.62,,,fee schedule,,,103.62,,,percent of total billed charges,,,,,,,,,103.62,,,percent of total billed charges,,,63.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.83,,,percent of total billed charges,,,,,,,,,,,,,,,55.95,,,percent of total billed charges,,,53.88,,,percent of total billed charges,,,56.99,,,percent of total billed charges,,,,,,,,,61.14,,,percent of total billed charges,,,548.68,,,per diem,,,103.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,103.62,,,percent of total billed charges,,,88.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.03,,,percent of total billed charges,,,103.62,,,percent of total billed charges,,,103.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.9,,,percent of total billed charges,,,83.85,,,percent of total billed charges,,,,,,,,,,,,,,,41.45,,,percent of total billed charges,,,,,,,,,38.34,,,percent of total billed charges,,,38.34,,,percent of total billed charges,,,,,,,,,103.62,,,percent of total billed charges,,,103.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,103.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.29,,,percent of total billed charges,,,103.62,,,percent of total billed charges,,,,,,,,,,,,,,,103.62,,,percent of total billed charges,,,103.62,,,percent of total billed charges,,,,,,,,,96.39,,,percent of total billed charges,,,,,,,,,,,,,,,96.39,,,percent of total billed charges,,,96.39,,,percent of total billed charges,,,96.39,,,percent of total billed charges,,,77.72,,,percent of total billed charges,,,103.62,,,percent of total billed charges,,,103.62,,,percent of total billed charges,,,103.62,,,percent of total billed charges,,,,,,,,,72.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,61.05,,,percent of total billed charges,,
METFORMIN 1000MG ER.24H,2500003498,CDM,637,RC,5074263460,NDC,999,EAPG,,,,outpatient,facility,1000,UN,103.62,103.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METFORMIN 500MG ER.24H,2500003499,CDM,637,RC,6068764001,NDC,,,,,,inpatient,facility,500,UN,2.04,2.04,0.16,2.04,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,
METFORMIN 500MG ER.24H,2500003499,CDM,637,RC,6068764001,NDC,,,,,,outpatient,facility,500,UN,2.04,2.04,0.16,548.68,,1.45,,,percent of total billed charges,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.04,,,percent of total billed charges,,,1.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.75,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.04,,,fee schedule,,,2.04,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,1.2,,,percent of total billed charges,,,548.68,,,per diem,,,2.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.04,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,0.75,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,2.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.2,,,percent of total billed charges,,
METFORMIN 500MG ER.24H,2500003499,CDM,637,RC,6068764001,NDC,999,EAPG,,,,outpatient,facility,500,UN,2.04,2.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TAFASITAMAB-CXIX 200 MG INJ,2500003505,CDM,636,RC,J9349,HCPCS,7353520801,NDC,,,,inpatient,facility,200,UN,4449.06,4449.06,355.92,4449.06,,,,,,,,,,,,,,4449.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4449.06,,,percent of total billed charges,,,,,,,,,4449.06,,,percent of total billed charges,,,2271.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3789.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2669.44,,,percent of total billed charges,,,,,,,,,,,,,,,4449.06,,,percent of total billed charges,,,3781.7,,,percent of total billed charges,,,,,,,,,,,,,,,4449.06,,,percent of total billed charges,,,2362.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1779.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4449.06,,,percent of total billed charges,,,,,,,,,,,,,,,355.92,,,percent of total billed charges,,,4449.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4449.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2621.39,,,percent of total billed charges,,
TAFASITAMAB-CXIX 200 MG INJ,2500003505,CDM,636,RC,J9349,HCPCS,7353520801,NDC,,,,outpatient,facility,200,UN,4449.06,4449.06,8.85,4449.06,,13.58,,,fee schedule,,,,,,,,,4449.06,,,percent of total billed charges,,,17.89,,,fee schedule,,,16.92,,,fee schedule,,,,,,,,,16.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4449.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4449.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4449.06,,,fee schedule,,,4449.06,,,percent of total billed charges,,,,,,,,,4449.06,,,percent of total billed charges,,,2726.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3169.96,,,percent of total billed charges,,,,,,,,,,,,,,,13.6,,,fee schedule,,,13.6,,,fee schedule,,,13.6,,,fee schedule,,,,,,,,,2624.95,,,percent of total billed charges,,,548.68,,,per diem,,,4449.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4449.06,,,percent of total billed charges,,,3781.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2362.9,,,percent of total billed charges,,,4449.06,,,percent of total billed charges,,,4449.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3001.34,,,percent of total billed charges,,,3600.18,,,percent of total billed charges,,,,,,,,,,,,,,,1779.62,,,percent of total billed charges,,,,,,,,,31.87,,,fee schedule,,,22.93,,,fee schedule,,,,,,,,,4449.06,,,percent of total billed charges,,,,,,,,,,,,,,,355.92,,,percent of total billed charges,,,4449.06,,,percent of total billed charges,,,,,,,,,,,,,,,4449.06,,,percent of total billed charges,,,4449.06,,,percent of total billed charges,,,,,,,,,13.62,,,fee schedule,,,,,,,,,,,,,,,11.81,,,fee schedule,,,15.74,,,fee schedule,,,8.85,,,fee schedule,,,14.3,,,fee schedule,,,4449.06,,,percent of total billed charges,,,4449.06,,,percent of total billed charges,,,4449.06,,,percent of total billed charges,,,,,,,,,3119.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2224.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2621.39,,,percent of total billed charges,,
TAFASITAMAB-CXIX 200 MG INJ,2500003505,CDM,636,RC,J9349,HCPCS,7353520801,NDC,9385,APC,,outpatient,facility,200,UN,4449.06,4449.06,13.41,1628.36,,,,,,,,14.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,13.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.11,,,fee schedule,,,,,,,,,1628.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,13.97,,,fee schedule,,,,,,,,,,,,,,,14.67,,,fee schedule,,,14.67,,,fee schedule,,,,,,,,,13.97,,,fee schedule,,,13.97,,,fee schedule,,,14.67,,,fee schedule,,,,,,,,,,,,,,,20.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,13.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.41,,,fee schedule,,,14.95,,,fee schedule,,,14.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.97,,,fee schedule,,,13.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,14.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,13.97,,,fee schedule,,,,,,,,,17.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,13.97,,,fee schedule,,,13.97,,,fee schedule,,,,,,,,,,,,,,,13.97,,,fee schedule,,,,,,,,,13.97,,,fee schedule,,,14.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.97,,,fee schedule,,,,,,,,,,,,,,,14.53,,,fee schedule,,,13.97,,,fee schedule,,,,,,,,,13.97,,,fee schedule,,,,,,,,,13.97,,,fee schedule,,,14.67,,,fee schedule,,,,,,,,
TAFASITAMAB-CXIX 200 MG INJ,2500003505,CDM,636,RC,J9349,HCPCS,7353520801,NDC,462,EAPG,,outpatient,facility,200,UN,4449.06,4449.06,4530.01,6840.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6840.32,,,fee schedule,,,4530.01,,,fee schedule,,,6081.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROTHROMBIN COMP CONC 500U,2500003523,CDM,636,RC,J7168,HCPCS,6383339601,NDC,,,,inpatient,facility,20,ML,3606.96,3606.96,288.56,3606.96,,,,,,,,,,,,,,3606.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3606.96,,,percent of total billed charges,,,,,,,,,3606.96,,,percent of total billed charges,,,1841.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3072.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2164.18,,,percent of total billed charges,,,,,,,,,,,,,,,3606.96,,,percent of total billed charges,,,3065.92,,,percent of total billed charges,,,,,,,,,,,,,,,3606.96,,,percent of total billed charges,,,1915.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1442.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3606.96,,,percent of total billed charges,,,,,,,,,,,,,,,288.56,,,percent of total billed charges,,,3606.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3606.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2125.22,,,percent of total billed charges,,
PROTHROMBIN COMP CONC 500U,2500003523,CDM,636,RC,J7168,HCPCS,6383339601,NDC,,,,outpatient,facility,20,ML,3606.96,3606.96,1.42,3606.96,,2557.7,,,percent of total billed charges,,,,,,,,,3606.96,,,percent of total billed charges,,,4.41,,,fee schedule,,,4.18,,,fee schedule,,,,,,,,,4.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3606.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3606.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3606.96,,,fee schedule,,,3606.96,,,percent of total billed charges,,,,,,,,,3606.96,,,percent of total billed charges,,,2210.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2569.96,,,percent of total billed charges,,,,,,,,,,,,,,,3.04,,,fee schedule,,,3.04,,,fee schedule,,,3.04,,,fee schedule,,,,,,,,,2128.11,,,percent of total billed charges,,,548.68,,,per diem,,,3606.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3606.96,,,percent of total billed charges,,,3065.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1915.66,,,percent of total billed charges,,,3606.96,,,percent of total billed charges,,,3606.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2433.26,,,percent of total billed charges,,,2918.75,,,percent of total billed charges,,,,,,,,,,,,,,,1442.78,,,percent of total billed charges,,,,,,,,,5.14,,,fee schedule,,,3.7,,,fee schedule,,,,,,,,,3606.96,,,percent of total billed charges,,,,,,,,,,,,,,,288.56,,,percent of total billed charges,,,3606.96,,,percent of total billed charges,,,,,,,,,,,,,,,3606.96,,,percent of total billed charges,,,3606.96,,,percent of total billed charges,,,,,,,,,2.19,,,fee schedule,,,,,,,,,,,,,,,1.91,,,fee schedule,,,2.54,,,fee schedule,,,1.42,,,fee schedule,,,2705.22,,,percent of total billed charges,,,3606.96,,,percent of total billed charges,,,3606.96,,,percent of total billed charges,,,3606.96,,,percent of total billed charges,,,,,,,,,2528.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1803.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2125.22,,,percent of total billed charges,,
PROTHROMBIN COMP CONC 500U,2500003523,CDM,636,RC,J7168,HCPCS,6383339601,NDC,9132,APC,,outpatient,facility,20,ML,3606.96,3606.96,2.12,1320.15,,,,,,,,2.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,2.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,fee schedule,,,,,,,,,1320.15,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,fee schedule,,,,,,,,,,,,,,,2.32,,,fee schedule,,,2.32,,,fee schedule,,,,,,,,,2.21,,,fee schedule,,,2.21,,,fee schedule,,,2.32,,,fee schedule,,,,,,,,,,,,,,,3.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.12,,,fee schedule,,,2.36,,,fee schedule,,,2.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,fee schedule,,,2.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,fee schedule,,,,,,,,,2.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,2.21,,,fee schedule,,,2.21,,,fee schedule,,,,,,,,,,,,,,,2.21,,,fee schedule,,,,,,,,,2.21,,,fee schedule,,,2.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,fee schedule,,,,,,,,,,,,,,,2.3,,,fee schedule,,,2.21,,,fee schedule,,,,,,,,,2.21,,,fee schedule,,,,,,,,,2.21,,,fee schedule,,,2.32,,,fee schedule,,,,,,,,
PROTHROMBIN COMP CONC 500U,2500003523,CDM,636,RC,J7168,HCPCS,6383339601,NDC,461,EAPG,,outpatient,facility,20,ML,3606.96,3606.96,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COVID-19 VAC 30MCG/0.3ML B,2500003552,CDM,,,,,,,,,,inpatient,facility,1,UN,0.03,0.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COVID-19 VAC 30MCG/0.3ML B,2500003552,CDM,,,,,,,,,,outpatient,facility,1,UN,0.03,0.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EFGARTIGIMOD ALFA-FCAB 400 MG/,2500003559,CDM,636,RC,J9332,HCPCS,7347530415,NDC,,,,inpatient,facility,20,ML,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
EFGARTIGIMOD ALFA-FCAB 400 MG/,2500003559,CDM,636,RC,J9332,HCPCS,7347530415,NDC,,,,outpatient,facility,20,ML,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,41.69,,,fee schedule,,,39.44,,,fee schedule,,,,,,,,,39.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
EFGARTIGIMOD ALFA-FCAB 400 MG/,2500003559,CDM,636,RC,J9332,HCPCS,7347530415,NDC,9010,APC,,outpatient,facility,20,ML,0.01,0.01,31.15,48.68,,,,,,,,33.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,32.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.45,,,fee schedule,,,,,,,,,,,,,,,34.07,,,fee schedule,,,34.07,,,fee schedule,,,,,,,,,32.45,,,fee schedule,,,32.45,,,fee schedule,,,34.07,,,fee schedule,,,,,,,,,,,,,,,48.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,32.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.15,,,fee schedule,,,34.72,,,fee schedule,,,34.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.45,,,fee schedule,,,32.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,33.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,32.45,,,fee schedule,,,,,,,,,40.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,32.45,,,fee schedule,,,32.45,,,fee schedule,,,,,,,,,,,,,,,32.45,,,fee schedule,,,,,,,,,32.45,,,fee schedule,,,33.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.45,,,fee schedule,,,,,,,,,,,,,,,33.75,,,fee schedule,,,32.45,,,fee schedule,,,,,,,,,32.45,,,fee schedule,,,,,,,,,32.45,,,fee schedule,,,34.07,,,fee schedule,,,,,,,,
EFGARTIGIMOD ALFA-FCAB 400 MG/,2500003559,CDM,636,RC,J9332,HCPCS,7347530415,NDC,464,EAPG,,outpatient,facility,20,ML,0.01,0.01,8990.76,13576.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13576.05,,,fee schedule,,,8990.76,,,fee schedule,,,12069.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8990.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8990.76,,,fee schedule,,,8990.76,,,fee schedule,,,8990.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,8990.76,,,fee schedule,,,,,,,,,,,,,,,8990.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COVID VAC (NOVAVAX) 5MCG/0.5ML,2500003566,CDM,636,RC,91304,CPT,,,,,,inpatient,facility,,,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
COVID VAC (NOVAVAX) 5MCG/0.5ML,2500003566,CDM,636,RC,91304,CPT,,,,,,outpatient,facility,,,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,192.38,,,fee schedule,,,182,,,fee schedule,,,,,,,,,182,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
COVID VAC (NOVAVAX) 5MCG/0.5ML,2500003566,CDM,636,RC,91304,CPT,414,EAPG,,,,outpatient,facility,,,0.01,0.01,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPINEPHRINE 10 MG/10 ML INJ,2500003571,CDM,636,RC,J0171,HCPCS,5428812001,NDC,,,,inpatient,facility,10,ML,313.5,313.5,25.08,313.5,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,313.5,,,percent of total billed charges,,,160.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.1,,,percent of total billed charges,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,266.47,,,percent of total billed charges,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,166.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,25.08,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.71,,,percent of total billed charges,,
EPINEPHRINE 10 MG/10 ML INJ,2500003571,CDM,636,RC,J0171,HCPCS,5428812001,NDC,,,,outpatient,facility,10,ML,313.5,313.5,0.49,548.68,,222.3,,,percent of total billed charges,,,76.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,313.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,114.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.49,,,fee schedule,,,313.5,,,fee schedule,,,313.5,,,percent of total billed charges,,,,,,,,,313.5,,,percent of total billed charges,,,192.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,184.96,,,percent of total billed charges,,,548.68,,,per diem,,,313.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,313.5,,,percent of total billed charges,,,266.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,166.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.49,,,percent of total billed charges,,,253.68,,,percent of total billed charges,,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,313.5,,,percent of total billed charges,,,313.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,313.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.08,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.84,,,fee schedule,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,219.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,184.71,,,percent of total billed charges,,
EPINEPHRINE 10 MG/10 ML INJ,2500003571,CDM,636,RC,J0171,HCPCS,5428812001,NDC,496,EAPG,,outpatient,facility,10,ML,313.5,313.5,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MENING VAC ACYW135C-TET/PF,2500003581,CDM,636,RC,90619,CPT,4928159005,NDC,,,,inpatient,facility,0.5,UN,512.69,512.69,41.02,512.69,,,,,,,,,,,,,,512.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.69,,,percent of total billed charges,,,,,,,,,512.69,,,percent of total billed charges,,,261.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,436.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.61,,,percent of total billed charges,,,,,,,,,,,,,,,512.69,,,percent of total billed charges,,,435.79,,,percent of total billed charges,,,,,,,,,,,,,,,512.69,,,percent of total billed charges,,,272.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,512.69,,,percent of total billed charges,,,,,,,,,,,,,,,41.02,,,percent of total billed charges,,,512.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,512.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.08,,,percent of total billed charges,,
MENING VAC ACYW135C-TET/PF,2500003581,CDM,636,RC,90619,CPT,4928159005,NDC,,,,outpatient,facility,0.5,UN,512.69,512.69,41.02,548.68,,363.55,,,percent of total billed charges,,,125.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,512.69,,,percent of total billed charges,,,259.9,,,fee schedule,,,245.88,,,fee schedule,,,,,,,,,245.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,512.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,187.64,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,512.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,512.69,,,fee schedule,,,512.69,,,percent of total billed charges,,,,,,,,,512.69,,,percent of total billed charges,,,314.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,365.29,,,percent of total billed charges,,,,,,,,,,,,,,,159.1,,,fee schedule,,,159.1,,,fee schedule,,,159.1,,,fee schedule,,,,,,,,,302.49,,,percent of total billed charges,,,548.68,,,per diem,,,512.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,512.69,,,percent of total billed charges,,,435.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,272.29,,,percent of total billed charges,,,512.69,,,percent of total billed charges,,,512.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.86,,,percent of total billed charges,,,414.87,,,percent of total billed charges,,,,,,,,,,,,,,,205.08,,,percent of total billed charges,,,,,,,,,189.7,,,percent of total billed charges,,,189.7,,,percent of total billed charges,,,,,,,,,512.69,,,percent of total billed charges,,,512.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,512.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,41.02,,,percent of total billed charges,,,512.69,,,percent of total billed charges,,,,,,,,,,,,,,,512.69,,,percent of total billed charges,,,512.69,,,percent of total billed charges,,,,,,,,,476.9,,,percent of total billed charges,,,,,,,,,,,,,,,476.9,,,percent of total billed charges,,,476.9,,,percent of total billed charges,,,476.9,,,percent of total billed charges,,,384.52,,,percent of total billed charges,,,512.69,,,percent of total billed charges,,,512.69,,,percent of total billed charges,,,512.69,,,percent of total billed charges,,,,,,,,,359.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,302.08,,,percent of total billed charges,,
MENING VAC ACYW135C-TET/PF,2500003581,CDM,636,RC,90619,CPT,4928159005,NDC,999,EAPG,,outpatient,facility,0.5,UN,512.69,512.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INCLISIRAN SOD 284MG/1.5ML SYR,2500003584,CDM,636,RC,J1306,HCPCS,78100060,NDC,,,,inpatient,facility,1.5,ML,11271.41,11271.41,901.71,11271.41,,,,,,,,,,,,,,11271.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11271.41,,,percent of total billed charges,,,,,,,,,11271.41,,,percent of total billed charges,,,5755.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9599.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6762.85,,,percent of total billed charges,,,,,,,,,,,,,,,11271.41,,,percent of total billed charges,,,9580.7,,,percent of total billed charges,,,,,,,,,,,,,,,11271.41,,,percent of total billed charges,,,5986.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4508.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11271.41,,,percent of total billed charges,,,,,,,,,,,,,,,901.71,,,percent of total billed charges,,,11271.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11271.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6641.11,,,percent of total billed charges,,
INCLISIRAN SOD 284MG/1.5ML SYR,2500003584,CDM,636,RC,J1306,HCPCS,78100060,NDC,,,,outpatient,facility,1.5,ML,11271.41,11271.41,8.22,11271.41,,7992.56,,,percent of total billed charges,,,,,,,,,11271.41,,,percent of total billed charges,,,15.85,,,fee schedule,,,14.99,,,fee schedule,,,,,,,,,14.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,11271.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11271.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,11271.41,,,fee schedule,,,11271.41,,,percent of total billed charges,,,,,,,,,11271.41,,,percent of total billed charges,,,6908.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8030.88,,,percent of total billed charges,,,,,,,,,,,,,,,12.13,,,fee schedule,,,12.13,,,fee schedule,,,12.13,,,fee schedule,,,,,,,,,6650.13,,,percent of total billed charges,,,548.68,,,per diem,,,11271.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11271.41,,,percent of total billed charges,,,9580.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5986.25,,,percent of total billed charges,,,11271.41,,,percent of total billed charges,,,11271.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7603.69,,,percent of total billed charges,,,9120.82,,,percent of total billed charges,,,,,,,,,,,,,,,4508.56,,,percent of total billed charges,,,,,,,,,29.61,,,fee schedule,,,21.3,,,fee schedule,,,,,,,,,11271.41,,,percent of total billed charges,,,,,,,,,,,,,,,901.71,,,percent of total billed charges,,,11271.41,,,percent of total billed charges,,,,,,,,,,,,,,,11271.41,,,percent of total billed charges,,,11271.41,,,percent of total billed charges,,,,,,,,,12.65,,,fee schedule,,,,,,,,,,,,,,,10.97,,,fee schedule,,,14.62,,,fee schedule,,,8.22,,,fee schedule,,,12.66,,,fee schedule,,,11271.41,,,percent of total billed charges,,,11271.41,,,percent of total billed charges,,,11271.41,,,percent of total billed charges,,,,,,,,,7902.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5635.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6641.11,,,percent of total billed charges,,
INCLISIRAN SOD 284MG/1.5ML SYR,2500003584,CDM,636,RC,J1306,HCPCS,78100060,NDC,9004,APC,,outpatient,facility,1.5,ML,11271.41,11271.41,11.79,4125.34,,,,,,,,12.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,12.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.4,,,fee schedule,,,,,,,,,4125.34,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,12.28,,,fee schedule,,,,,,,,,,,,,,,12.89,,,fee schedule,,,12.89,,,fee schedule,,,,,,,,,12.28,,,fee schedule,,,12.28,,,fee schedule,,,12.89,,,fee schedule,,,,,,,,,,,,,,,18.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,12.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.79,,,fee schedule,,,13.14,,,fee schedule,,,12.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.28,,,fee schedule,,,12.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,12.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,12.28,,,fee schedule,,,,,,,,,15.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,12.28,,,fee schedule,,,12.28,,,fee schedule,,,,,,,,,,,,,,,12.28,,,fee schedule,,,,,,,,,12.28,,,fee schedule,,,12.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.28,,,fee schedule,,,,,,,,,,,,,,,12.77,,,fee schedule,,,12.28,,,fee schedule,,,,,,,,,12.28,,,fee schedule,,,,,,,,,12.28,,,fee schedule,,,12.89,,,fee schedule,,,,,,,,
INCLISIRAN SOD 284MG/1.5ML SYR,2500003584,CDM,636,RC,J1306,HCPCS,78100060,NDC,461,EAPG,,outpatient,facility,1.5,ML,11271.41,11271.41,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESOMEPRAZOLE 40MG PKT,2500003617,CDM,637,RC,6909752934,NDC,,,,,,inpatient,facility,40,UN,32.21,32.21,2.58,32.21,,,,,,,,,,,,,,32.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.21,,,percent of total billed charges,,,,,,,,,32.21,,,percent of total billed charges,,,16.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.33,,,percent of total billed charges,,,,,,,,,,,,,,,32.21,,,percent of total billed charges,,,27.38,,,percent of total billed charges,,,,,,,,,,,,,,,32.21,,,percent of total billed charges,,,17.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,32.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,32.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.98,,,percent of total billed charges,,
ESOMEPRAZOLE 40MG PKT,2500003617,CDM,637,RC,6909752934,NDC,,,,,,outpatient,facility,40,UN,32.21,32.21,2.58,548.68,,22.84,,,percent of total billed charges,,,7.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,32.21,,,percent of total billed charges,,,20.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,22.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,22.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,32.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.79,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,32.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,32.21,,,fee schedule,,,32.21,,,percent of total billed charges,,,,,,,,,32.21,,,percent of total billed charges,,,19.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.95,,,percent of total billed charges,,,,,,,,,,,,,,,17.39,,,percent of total billed charges,,,16.75,,,percent of total billed charges,,,17.72,,,percent of total billed charges,,,,,,,,,19,,,percent of total billed charges,,,548.68,,,per diem,,,32.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,32.21,,,percent of total billed charges,,,27.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.11,,,percent of total billed charges,,,32.21,,,percent of total billed charges,,,32.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.73,,,percent of total billed charges,,,26.06,,,percent of total billed charges,,,,,,,,,,,,,,,12.88,,,percent of total billed charges,,,,,,,,,11.92,,,percent of total billed charges,,,11.92,,,percent of total billed charges,,,,,,,,,32.21,,,percent of total billed charges,,,32.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,32.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.58,,,percent of total billed charges,,,32.21,,,percent of total billed charges,,,,,,,,,,,,,,,32.21,,,percent of total billed charges,,,32.21,,,percent of total billed charges,,,,,,,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,24.16,,,percent of total billed charges,,,32.21,,,percent of total billed charges,,,32.21,,,percent of total billed charges,,,32.21,,,percent of total billed charges,,,,,,,,,22.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.11,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.98,,,percent of total billed charges,,
ESOMEPRAZOLE 40MG PKT,2500003617,CDM,637,RC,6909752934,NDC,999,EAPG,,,,outpatient,facility,40,UN,32.21,32.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LABETALOL HCL 20MG/4MG INJ,2500003618,CDM,250,RC,J3490,HCPCS,3600032010,NDC,,,,inpatient,facility,4,UN,13.93,13.93,1.11,13.93,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,13.93,,,percent of total billed charges,,,7.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.36,,,percent of total billed charges,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,11.84,,,percent of total billed charges,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.21,,,percent of total billed charges,,
LABETALOL HCL 20MG/4MG INJ,2500003618,CDM,250,RC,J3490,HCPCS,3600032010,NDC,,,,outpatient,facility,4,UN,13.93,13.93,1.11,548.68,,9.88,,,percent of total billed charges,,,3.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.93,,,percent of total billed charges,,,8.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,13.93,,,fee schedule,,,13.93,,,percent of total billed charges,,,,,,,,,13.93,,,percent of total billed charges,,,8.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,8.22,,,percent of total billed charges,,,548.68,,,per diem,,,13.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.93,,,percent of total billed charges,,,11.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.4,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.4,,,percent of total billed charges,,,11.27,,,percent of total billed charges,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13.93,,,percent of total billed charges,,,13.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.11,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,10.45,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,9.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.21,,,percent of total billed charges,,
LABETALOL HCL 20MG/4MG INJ,2500003618,CDM,250,RC,J3490,HCPCS,3600032010,NDC,435,EAPG,,outpatient,facility,4,UN,13.93,13.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHOTREXATE ORAL 2.5 MG,2500003630,CDM,637,RC,J8610,HCPCS,6838277501,NDC,,,,inpatient,facility,2.5,UN,11.74,11.74,0.94,11.74,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,,,,,,,11.74,,,percent of total billed charges,,,5.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.04,,,percent of total billed charges,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,9.98,,,percent of total billed charges,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,6.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.92,,,percent of total billed charges,,
METHOTREXATE ORAL 2.5 MG,2500003630,CDM,637,RC,J8610,HCPCS,6838277501,NDC,,,,outpatient,facility,2.5,UN,11.74,11.74,0.24,548.68,,0.24,,,fee schedule,,,2.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,11.74,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,11.74,,,fee schedule,,,11.74,,,percent of total billed charges,,,,,,,,,11.74,,,percent of total billed charges,,,7.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,6.93,,,percent of total billed charges,,,548.68,,,per diem,,,11.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11.74,,,percent of total billed charges,,,9.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.24,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,4.7,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11.74,,,percent of total billed charges,,,11.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.94,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.25,,,fee schedule,,,11.74,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,,,,,,,8.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.92,,,percent of total billed charges,,
METHOTREXATE ORAL 2.5 MG,2500003630,CDM,637,RC,J8610,HCPCS,6838277501,NDC,999,EAPG,,outpatient,facility,2.5,UN,11.74,11.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIPHTHPERTUSS(ACELL)TET VAC,2500003633,CDM,636,RC,90715,CPT,5816084252,NDC,,,,inpatient,facility,0.5,UN,148.96,148.96,11.92,148.96,,,,,,,,,,,,,,148.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.96,,,percent of total billed charges,,,,,,,,,148.96,,,percent of total billed charges,,,76.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.38,,,percent of total billed charges,,,,,,,,,,,,,,,148.96,,,percent of total billed charges,,,126.62,,,percent of total billed charges,,,,,,,,,,,,,,,148.96,,,percent of total billed charges,,,79.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,148.96,,,percent of total billed charges,,,,,,,,,,,,,,,11.92,,,percent of total billed charges,,,148.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,148.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.77,,,percent of total billed charges,,
DIPHTHPERTUSS(ACELL)TET VAC,2500003633,CDM,636,RC,90715,CPT,5816084252,NDC,,,,outpatient,facility,0.5,UN,148.96,148.96,11.92,548.68,,105.63,,,percent of total billed charges,,,36.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,148.96,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,148.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,54.52,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,38.54,,,fee schedule,,,148.96,,,fee schedule,,,148.96,,,percent of total billed charges,,,,,,,,,148.96,,,percent of total billed charges,,,91.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,87.89,,,percent of total billed charges,,,548.68,,,per diem,,,148.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,148.96,,,percent of total billed charges,,,126.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.11,,,percent of total billed charges,,,148.96,,,percent of total billed charges,,,148.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.49,,,percent of total billed charges,,,120.54,,,percent of total billed charges,,,,,,,,,,,,,,,59.58,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,148.96,,,percent of total billed charges,,,148.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,148.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.92,,,percent of total billed charges,,,148.96,,,percent of total billed charges,,,,,,,,,,,,,,,148.96,,,percent of total billed charges,,,148.96,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,39.73,,,fee schedule,,,148.96,,,percent of total billed charges,,,148.96,,,percent of total billed charges,,,148.96,,,percent of total billed charges,,,,,,,,,104.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,87.77,,,percent of total billed charges,,
DIPHTHPERTUSS(ACELL)TET VAC,2500003633,CDM,636,RC,90715,CPT,5816084252,NDC,414,EAPG,,outpatient,facility,0.5,UN,148.96,148.96,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MENING VAC ACYW-135 DIP/PF,2500003634,CDM,636,RC,90714,CPT,5816095509,NDC,,,,inpatient,facility,0.5,UN,487.54,487.54,39,487.54,,,,,,,,,,,,,,487.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.54,,,percent of total billed charges,,,,,,,,,487.54,,,percent of total billed charges,,,248.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,415.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,292.52,,,percent of total billed charges,,,,,,,,,,,,,,,487.54,,,percent of total billed charges,,,414.41,,,percent of total billed charges,,,,,,,,,,,,,,,487.54,,,percent of total billed charges,,,258.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,487.54,,,percent of total billed charges,,,,,,,,,,,,,,,39,,,percent of total billed charges,,,487.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,487.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.26,,,percent of total billed charges,,
MENING VAC ACYW-135 DIP/PF,2500003634,CDM,636,RC,90714,CPT,5816095509,NDC,,,,outpatient,facility,0.5,UN,487.54,487.54,23.55,548.68,,345.71,,,percent of total billed charges,,,118.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,487.54,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,487.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,178.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,23.55,,,fee schedule,,,43.66,,,fee schedule,,,487.54,,,percent of total billed charges,,,,,,,,,487.54,,,percent of total billed charges,,,298.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,347.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,287.65,,,percent of total billed charges,,,548.68,,,per diem,,,487.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,487.54,,,percent of total billed charges,,,414.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,258.93,,,percent of total billed charges,,,487.54,,,percent of total billed charges,,,487.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.89,,,percent of total billed charges,,,394.52,,,percent of total billed charges,,,,,,,,,,,,,,,195.02,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,487.54,,,percent of total billed charges,,,487.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,487.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,39,,,percent of total billed charges,,,487.54,,,percent of total billed charges,,,,,,,,,,,,,,,487.54,,,percent of total billed charges,,,487.54,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,28.86,,,fee schedule,,,487.54,,,percent of total billed charges,,,487.54,,,percent of total billed charges,,,487.54,,,percent of total billed charges,,,,,,,,,341.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,287.26,,,percent of total billed charges,,
MENING VAC ACYW-135 DIP/PF,2500003634,CDM,636,RC,90714,CPT,5816095509,NDC,414,EAPG,,outpatient,facility,0.5,UN,487.54,487.54,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEASLESMUMPSRUBELLA VACC/PF,2500003635,CDM,636,RC,90707,CPT,5816082415,NDC,,,,inpatient,facility,0.5,UN,297.79,297.79,23.82,297.79,,,,,,,,,,,,,,297.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,297.79,,,percent of total billed charges,,,,,,,,,297.79,,,percent of total billed charges,,,152.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.67,,,percent of total billed charges,,,,,,,,,,,,,,,297.79,,,percent of total billed charges,,,253.12,,,percent of total billed charges,,,,,,,,,,,,,,,297.79,,,percent of total billed charges,,,158.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,297.79,,,percent of total billed charges,,,,,,,,,,,,,,,23.82,,,percent of total billed charges,,,297.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,297.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.46,,,percent of total billed charges,,
MEASLESMUMPSRUBELLA VACC/PF,2500003635,CDM,636,RC,90707,CPT,5816082415,NDC,,,,outpatient,facility,0.5,UN,297.79,297.79,23.82,548.68,,211.16,,,percent of total billed charges,,,72.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,297.79,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,297.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,108.99,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,53.66,,,fee schedule,,,297.79,,,fee schedule,,,297.79,,,percent of total billed charges,,,,,,,,,297.79,,,percent of total billed charges,,,182.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,212.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,175.7,,,percent of total billed charges,,,548.68,,,per diem,,,297.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,297.79,,,percent of total billed charges,,,253.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,158.16,,,percent of total billed charges,,,297.79,,,percent of total billed charges,,,297.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200.89,,,percent of total billed charges,,,240.97,,,percent of total billed charges,,,,,,,,,,,,,,,119.12,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,297.79,,,percent of total billed charges,,,297.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,297.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.82,,,percent of total billed charges,,,297.79,,,percent of total billed charges,,,,,,,,,,,,,,,297.79,,,percent of total billed charges,,,297.79,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,54.47,,,fee schedule,,,297.79,,,percent of total billed charges,,,297.79,,,percent of total billed charges,,,297.79,,,percent of total billed charges,,,,,,,,,208.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,175.46,,,percent of total billed charges,,
MEASLESMUMPSRUBELLA VACC/PF,2500003635,CDM,636,RC,90707,CPT,5816082415,NDC,414,EAPG,,outpatient,facility,0.5,UN,297.79,297.79,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIPHPERTUSS(ACELL)TET PED/PF,2500003637,CDM,636,RC,90686,CPT,5816081052,NDC,,,,inpatient,facility,0.5,UN,85.04,85.04,6.8,85.04,,,,,,,,,,,,,,85.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.04,,,percent of total billed charges,,,,,,,,,85.04,,,percent of total billed charges,,,43.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,85.04,,,percent of total billed charges,,,72.28,,,percent of total billed charges,,,,,,,,,,,,,,,85.04,,,percent of total billed charges,,,45.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,85.04,,,percent of total billed charges,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,85.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.11,,,percent of total billed charges,,
DIPHPERTUSS(ACELL)TET PED/PF,2500003637,CDM,636,RC,90686,CPT,5816081052,NDC,,,,outpatient,facility,0.5,UN,85.04,85.04,6.8,548.68,,60.3,,,percent of total billed charges,,,16.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,85.04,,,percent of total billed charges,,,29.01,,,fee schedule,,,27.45,,,fee schedule,,,15.84,,,fee schedule,,,27.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,85.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16,,,fee schedule,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,15.84,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,85.04,,,fee schedule,,,85.04,,,percent of total billed charges,,,15.84,,,fee schedule,,,85.04,,,percent of total billed charges,,,52.12,,,percent of total billed charges,,,16.63,,,fee schedule,,,16.63,,,fee schedule,,,,,,,,,16.16,,,fee schedule,,,15.84,,,fee schedule,,,16.63,,,fee schedule,,,60.59,,,percent of total billed charges,,,,,,,,,23.76,,,fee schedule,,,22.35,,,fee schedule,,,22.35,,,fee schedule,,,22.35,,,fee schedule,,,16.31,,,fee schedule,,,50.17,,,percent of total billed charges,,,548.68,,,per diem,,,85.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,85.04,,,percent of total billed charges,,,72.28,,,percent of total billed charges,,,15.29,,,fee schedule,,,16.95,,,fee schedule,,,16.97,,,fee schedule,,,45.16,,,percent of total billed charges,,,85.04,,,percent of total billed charges,,,85.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.84,,,fee schedule,,,15.84,,,fee schedule,,,57.37,,,percent of total billed charges,,,68.81,,,percent of total billed charges,,,,,,,,,16.81,,,fee schedule,,,34.02,,,percent of total billed charges,,,,,,,,,52.87,,,fee schedule,,,38.05,,,fee schedule,,,15.84,,,fee schedule,,,85.04,,,percent of total billed charges,,,19.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.8,,,percent of total billed charges,,,85.04,,,percent of total billed charges,,,15.84,,,fee schedule,,,23.76,,,fee schedule,,,85.04,,,percent of total billed charges,,,85.04,,,percent of total billed charges,,,15.84,,,fee schedule,,,22.6,,,fee schedule,,,15.84,,,fee schedule,,,16.32,,,fee schedule,,,19.58,,,fee schedule,,,26.11,,,fee schedule,,,14.69,,,fee schedule,,,23.19,,,fee schedule,,,85.04,,,percent of total billed charges,,,85.04,,,percent of total billed charges,,,85.04,,,percent of total billed charges,,,20.75,,,fee schedule,,,59.62,,,percent of total billed charges,,,15.84,,,fee schedule,,,16.89,,,fee schedule,,,15.84,,,fee schedule,,,15.84,,,fee schedule,,,16.16,,,fee schedule,,,42.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.16,,,fee schedule,,,16.63,,,fee schedule,,,50.11,,,percent of total billed charges,,
DIPHPERTUSS(ACELL)TET PED/PF,2500003637,CDM,636,RC,90686,CPT,5816081052,NDC,414,EAPG,,outpatient,facility,0.5,UN,85.04,85.04,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXORUBICIN 10 MG INJ,2500003640,CDM,636,RC,J9000,HCPCS,6332388305,NDC,,,,inpatient,facility,5,UN,29.7,29.7,2.38,29.7,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,29.7,,,percent of total billed charges,,,15.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,25.24,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,15.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.5,,,percent of total billed charges,,
DOXORUBICIN 10 MG INJ,2500003640,CDM,636,RC,J9000,HCPCS,6332388305,NDC,,,,outpatient,facility,5,UN,29.7,29.7,2.38,548.68,,3.65,,,fee schedule,,,7.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,29.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.45,,,fee schedule,,,29.7,,,fee schedule,,,29.7,,,percent of total billed charges,,,,,,,,,29.7,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,17.52,,,percent of total billed charges,,,548.68,,,per diem,,,29.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,29.7,,,percent of total billed charges,,,25.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.77,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.04,,,percent of total billed charges,,,24.03,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,29.7,,,percent of total billed charges,,,29.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.38,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.39,,,fee schedule,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,20.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.5,,,percent of total billed charges,,
DOXORUBICIN 10 MG INJ,2500003640,CDM,636,RC,J9000,HCPCS,6332388305,NDC,430,EAPG,,outpatient,facility,5,UN,29.7,29.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFAZOLIN 3 GM INJ,2500003647,CDM,636,RC,J0690,HCPCS,143914025,NDC,,,,inpatient,facility,3,UN,28.97,28.97,2.32,28.97,,,,,,,,,,,,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.97,,,percent of total billed charges,,,,,,,,,28.97,,,percent of total billed charges,,,14.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.38,,,percent of total billed charges,,,,,,,,,,,,,,,28.97,,,percent of total billed charges,,,24.62,,,percent of total billed charges,,,,,,,,,,,,,,,28.97,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.07,,,percent of total billed charges,,
CEFAZOLIN 3 GM INJ,2500003647,CDM,636,RC,J0690,HCPCS,143914025,NDC,,,,outpatient,facility,3,UN,28.97,28.97,0.71,548.68,,20.54,,,percent of total billed charges,,,7.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,28.97,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.6,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.71,,,fee schedule,,,28.97,,,fee schedule,,,28.97,,,percent of total billed charges,,,,,,,,,28.97,,,percent of total billed charges,,,17.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,17.09,,,percent of total billed charges,,,548.68,,,per diem,,,28.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,28.97,,,percent of total billed charges,,,24.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.39,,,percent of total billed charges,,,28.97,,,percent of total billed charges,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.54,,,percent of total billed charges,,,23.44,,,percent of total billed charges,,,,,,,,,,,,,,,11.59,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,28.97,,,percent of total billed charges,,,28.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.32,,,percent of total billed charges,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,,28.97,,,percent of total billed charges,,,28.97,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,28.97,,,percent of total billed charges,,,28.97,,,percent of total billed charges,,,28.97,,,percent of total billed charges,,,,,,,,,20.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.07,,,percent of total billed charges,,
CEFAZOLIN 3 GM INJ,2500003647,CDM,636,RC,J0690,HCPCS,143914025,NDC,496,EAPG,,outpatient,facility,3,UN,28.97,28.97,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXORUBICIN LIPID INJ 20 MG,2500003650,CDM,636,RC,Q2050,HCPCS,4359828335,NDC,,,,inpatient,facility,10,GR,1485,1485,118.8,1485,,,,,,,,,,,,,,1485,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1485,,,percent of total billed charges,,,,,,,,,1485,,,percent of total billed charges,,,758.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1264.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,891,,,percent of total billed charges,,,,,,,,,,,,,,,1485,,,percent of total billed charges,,,1262.25,,,percent of total billed charges,,,,,,,,,,,,,,,1485,,,percent of total billed charges,,,788.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,594,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1485,,,percent of total billed charges,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,1485,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1485,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,874.96,,,percent of total billed charges,,
DOXORUBICIN LIPID INJ 20 MG,2500003650,CDM,636,RC,Q2050,HCPCS,4359828335,NDC,,,,outpatient,facility,10,GR,1485,1485,76.43,1485,,114.94,,,fee schedule,,,,,,,,,1485,,,percent of total billed charges,,,176.83,,,fee schedule,,,167.29,,,fee schedule,,,,,,,,,167.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1485,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1485,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1485,,,fee schedule,,,1485,,,percent of total billed charges,,,,,,,,,1485,,,percent of total billed charges,,,910.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1058.06,,,percent of total billed charges,,,,,,,,,,,,,,,85.48,,,fee schedule,,,85.48,,,fee schedule,,,85.48,,,fee schedule,,,,,,,,,876.15,,,percent of total billed charges,,,548.68,,,per diem,,,1485,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1485,,,percent of total billed charges,,,1262.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,788.68,,,percent of total billed charges,,,1485,,,percent of total billed charges,,,1485,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.78,,,percent of total billed charges,,,1201.66,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,percent of total billed charges,,,,,,,,,275.16,,,fee schedule,,,198,,,fee schedule,,,,,,,,,1485,,,percent of total billed charges,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,1485,,,percent of total billed charges,,,,,,,,,,,,,,,1485,,,percent of total billed charges,,,1485,,,percent of total billed charges,,,,,,,,,117.59,,,fee schedule,,,,,,,,,,,,,,,101.92,,,fee schedule,,,135.89,,,fee schedule,,,76.43,,,fee schedule,,,119.27,,,fee schedule,,,1485,,,percent of total billed charges,,,1485,,,percent of total billed charges,,,1485,,,percent of total billed charges,,,,,,,,,1041.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,874.96,,,percent of total billed charges,,
DOXORUBICIN LIPID INJ 20 MG,2500003650,CDM,636,RC,Q2050,HCPCS,4359828335,NDC,7046,APC,,outpatient,facility,10,GR,1485,1485,130.61,543.51,,,,,,,,140.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,136.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.41,,,fee schedule,,,,,,,,,543.51,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,136.05,,,fee schedule,,,,,,,,,,,,,,,142.85,,,fee schedule,,,142.85,,,fee schedule,,,,,,,,,136.05,,,fee schedule,,,136.05,,,fee schedule,,,142.85,,,fee schedule,,,,,,,,,,,,,,,204.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,136.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.61,,,fee schedule,,,145.57,,,fee schedule,,,142.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.05,,,fee schedule,,,136.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,136.05,,,fee schedule,,,,,,,,,170.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,170.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,136.05,,,fee schedule,,,136.05,,,fee schedule,,,,,,,,,,,,,,,136.05,,,fee schedule,,,,,,,,,136.05,,,fee schedule,,,140.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.05,,,fee schedule,,,,,,,,,,,,,,,141.49,,,fee schedule,,,136.05,,,fee schedule,,,,,,,,,136.05,,,fee schedule,,,,,,,,,136.05,,,fee schedule,,,142.85,,,fee schedule,,,,,,,,
DOXORUBICIN LIPID INJ 20 MG,2500003650,CDM,636,RC,Q2050,HCPCS,4359828335,NDC,440,EAPG,,outpatient,facility,10,GR,1485,1485,746.59,1127.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1127.35,,,fee schedule,,,746.59,,,fee schedule,,,1002.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.59,,,fee schedule,,,746.59,,,fee schedule,,,746.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,746.59,,,fee schedule,,,,,,,,,,,,,,,746.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXORUBICIN LIPID INJ 50 MG,2500003651,CDM,636,RC,Q2050,HCPCS,4359854125,NDC,,,,inpatient,facility,25,ML,4125,4125,330,4125,,,,,,,,,,,,,,4125,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4125,,,percent of total billed charges,,,,,,,,,4125,,,percent of total billed charges,,,2106.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3513.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2475,,,percent of total billed charges,,,,,,,,,,,,,,,4125,,,percent of total billed charges,,,3506.25,,,percent of total billed charges,,,,,,,,,,,,,,,4125,,,percent of total billed charges,,,2190.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1650,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4125,,,percent of total billed charges,,,,,,,,,,,,,,,330,,,percent of total billed charges,,,4125,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4125,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2430.45,,,percent of total billed charges,,
DOXORUBICIN LIPID INJ 50 MG,2500003651,CDM,636,RC,Q2050,HCPCS,4359854125,NDC,,,,outpatient,facility,25,ML,4125,4125,76.43,4125,,114.94,,,fee schedule,,,,,,,,,4125,,,percent of total billed charges,,,176.83,,,fee schedule,,,167.29,,,fee schedule,,,,,,,,,167.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4125,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4125,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4125,,,fee schedule,,,4125,,,percent of total billed charges,,,,,,,,,4125,,,percent of total billed charges,,,2528.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2939.06,,,percent of total billed charges,,,,,,,,,,,,,,,85.48,,,fee schedule,,,85.48,,,fee schedule,,,85.48,,,fee schedule,,,,,,,,,2433.75,,,percent of total billed charges,,,548.68,,,per diem,,,4125,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4125,,,percent of total billed charges,,,3506.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2190.79,,,percent of total billed charges,,,4125,,,percent of total billed charges,,,4125,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2782.72,,,percent of total billed charges,,,3337.95,,,percent of total billed charges,,,,,,,,,,,,,,,1650,,,percent of total billed charges,,,,,,,,,275.16,,,fee schedule,,,198,,,fee schedule,,,,,,,,,4125,,,percent of total billed charges,,,,,,,,,,,,,,,330,,,percent of total billed charges,,,4125,,,percent of total billed charges,,,,,,,,,,,,,,,4125,,,percent of total billed charges,,,4125,,,percent of total billed charges,,,,,,,,,117.59,,,fee schedule,,,,,,,,,,,,,,,101.92,,,fee schedule,,,135.89,,,fee schedule,,,76.43,,,fee schedule,,,119.27,,,fee schedule,,,4125,,,percent of total billed charges,,,4125,,,percent of total billed charges,,,4125,,,percent of total billed charges,,,,,,,,,2892.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2062.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2430.45,,,percent of total billed charges,,
DOXORUBICIN LIPID INJ 50 MG,2500003651,CDM,636,RC,Q2050,HCPCS,4359854125,NDC,7046,APC,,outpatient,facility,25,ML,4125,4125,130.61,1509.75,,,,,,,,140.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,136.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.41,,,fee schedule,,,,,,,,,1509.75,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,136.05,,,fee schedule,,,,,,,,,,,,,,,142.85,,,fee schedule,,,142.85,,,fee schedule,,,,,,,,,136.05,,,fee schedule,,,136.05,,,fee schedule,,,142.85,,,fee schedule,,,,,,,,,,,,,,,204.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,136.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.61,,,fee schedule,,,145.57,,,fee schedule,,,142.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.05,,,fee schedule,,,136.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,141.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,136.05,,,fee schedule,,,,,,,,,170.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,170.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,136.05,,,fee schedule,,,136.05,,,fee schedule,,,,,,,,,,,,,,,136.05,,,fee schedule,,,,,,,,,136.05,,,fee schedule,,,140.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.05,,,fee schedule,,,,,,,,,,,,,,,141.49,,,fee schedule,,,136.05,,,fee schedule,,,,,,,,,136.05,,,fee schedule,,,,,,,,,136.05,,,fee schedule,,,142.85,,,fee schedule,,,,,,,,
DOXORUBICIN LIPID INJ 50 MG,2500003651,CDM,636,RC,Q2050,HCPCS,4359854125,NDC,440,EAPG,,outpatient,facility,25,ML,4125,4125,746.59,1127.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1127.35,,,fee schedule,,,746.59,,,fee schedule,,,1002.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.59,,,fee schedule,,,746.59,,,fee schedule,,,746.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,746.59,,,fee schedule,,,,,,,,,,,,,,,746.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYCODONE 10 MG TABLET,2500003656,CDM,637,RC,406851001,NDC,,,,,,inpatient,facility,10,UN,4.03,4.03,0.32,4.03,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,4.03,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.42,,,percent of total billed charges,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,
OXYCODONE 10 MG TABLET,2500003656,CDM,637,RC,406851001,NDC,,,,,,outpatient,facility,10,UN,4.03,4.03,0.32,548.68,,2.86,,,percent of total billed charges,,,0.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.03,,,percent of total billed charges,,,2.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.47,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.03,,,fee schedule,,,4.03,,,percent of total billed charges,,,,,,,,,4.03,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.1,,,percent of total billed charges,,,2.22,,,percent of total billed charges,,,,,,,,,2.38,,,percent of total billed charges,,,548.68,,,per diem,,,4.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.03,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,1.49,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,4.03,,,percent of total billed charges,,,4.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.32,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,3.75,,,percent of total billed charges,,,,,,,,,,,,,,,3.75,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,3.02,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,2.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.37,,,percent of total billed charges,,
OXYCODONE 10 MG TABLET,2500003656,CDM,637,RC,406851001,NDC,999,EAPG,,,,outpatient,facility,10,UN,4.03,4.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MIRVETIMAB SORAVTAN-GYNX 100MG,2500003668,CDM,636,RC,J9063,HCPCS,7290385301,NDC,,,,inpatient,facility,20,ML,20526,20526,1642.08,20526,,,,,,,,,,,,,,20526,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20526,,,percent of total billed charges,,,,,,,,,20526,,,percent of total billed charges,,,10480.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17481.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12315.6,,,percent of total billed charges,,,,,,,,,,,,,,,20526,,,percent of total billed charges,,,17447.1,,,percent of total billed charges,,,,,,,,,,,,,,,20526,,,percent of total billed charges,,,10901.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8210.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,20526,,,percent of total billed charges,,,,,,,,,,,,,,,1642.08,,,percent of total billed charges,,,20526,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20526,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12093.92,,,percent of total billed charges,,
MIRVETIMAB SORAVTAN-GYNX 100MG,2500003668,CDM,636,RC,J9063,HCPCS,7290385301,NDC,,,,outpatient,facility,20,ML,20526,20526,44.91,20526,,14554.99,,,percent of total billed charges,,,,,,,,,20526,,,percent of total billed charges,,,86.8,,,fee schedule,,,82.12,,,fee schedule,,,,,,,,,82.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,20526,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,20526,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,20526,,,fee schedule,,,20526,,,percent of total billed charges,,,,,,,,,20526,,,percent of total billed charges,,,12580.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14624.77,,,percent of total billed charges,,,,,,,,,,,,,,,65.71,,,fee schedule,,,65.71,,,fee schedule,,,65.71,,,fee schedule,,,,,,,,,12110.34,,,percent of total billed charges,,,548.68,,,per diem,,,20526,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,20526,,,percent of total billed charges,,,17447.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10901.36,,,percent of total billed charges,,,20526,,,percent of total billed charges,,,20526,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13846.84,,,percent of total billed charges,,,16609.64,,,percent of total billed charges,,,,,,,,,,,,,,,8210.4,,,percent of total billed charges,,,,,,,,,161.67,,,fee schedule,,,116.33,,,fee schedule,,,,,,,,,20526,,,percent of total billed charges,,,,,,,,,,,,,,,1642.08,,,percent of total billed charges,,,20526,,,percent of total billed charges,,,,,,,,,,,,,,,20526,,,percent of total billed charges,,,20526,,,percent of total billed charges,,,,,,,,,69.09,,,fee schedule,,,,,,,,,,,,,,,59.88,,,fee schedule,,,79.84,,,fee schedule,,,44.91,,,fee schedule,,,69.39,,,fee schedule,,,20526,,,percent of total billed charges,,,20526,,,percent of total billed charges,,,20526,,,percent of total billed charges,,,,,,,,,14390.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10263,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,12093.92,,,percent of total billed charges,,
MIRVETIMAB SORAVTAN-GYNX 100MG,2500003668,CDM,636,RC,J9063,HCPCS,7290385301,NDC,9109,APC,,outpatient,facility,20,ML,20526,20526,65.39,7512.52,,,,,,,,70.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,68.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.79,,,fee schedule,,,,,,,,,7512.52,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,68.11,,,fee schedule,,,,,,,,,,,,,,,71.52,,,fee schedule,,,71.52,,,fee schedule,,,,,,,,,68.11,,,fee schedule,,,68.11,,,fee schedule,,,71.52,,,fee schedule,,,,,,,,,,,,,,,102.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,68.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.39,,,fee schedule,,,72.88,,,fee schedule,,,71.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.11,,,fee schedule,,,68.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,70.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,68.11,,,fee schedule,,,,,,,,,85.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,85.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,68.11,,,fee schedule,,,68.11,,,fee schedule,,,,,,,,,,,,,,,68.11,,,fee schedule,,,,,,,,,68.11,,,fee schedule,,,70.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.11,,,fee schedule,,,,,,,,,,,,,,,70.83,,,fee schedule,,,68.11,,,fee schedule,,,,,,,,,68.11,,,fee schedule,,,,,,,,,68.11,,,fee schedule,,,71.52,,,fee schedule,,,,,,,,
MIRVETIMAB SORAVTAN-GYNX 100MG,2500003668,CDM,636,RC,J9063,HCPCS,7290385301,NDC,465,EAPG,,outpatient,facility,20,ML,20526,20526,20061.71,30293.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30293.18,,,fee schedule,,,20061.71,,,fee schedule,,,26930.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20061.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20061.71,,,fee schedule,,,20061.71,,,fee schedule,,,20061.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,20061.71,,,fee schedule,,,,,,,,,,,,,,,20061.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCIUM GLUC/NS 2 GM/100 ML,2500003678,CDM,250,RC,J0613,HCPCS,4456762124,NDC,,,,inpatient,facility,100,UN,156.42,156.42,12.51,156.42,,,,,,,,,,,,,,156.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.42,,,percent of total billed charges,,,,,,,,,156.42,,,percent of total billed charges,,,79.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.85,,,percent of total billed charges,,,,,,,,,,,,,,,156.42,,,percent of total billed charges,,,132.96,,,percent of total billed charges,,,,,,,,,,,,,,,156.42,,,percent of total billed charges,,,83.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,156.42,,,percent of total billed charges,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,156.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,156.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.16,,,percent of total billed charges,,
CALCIUM GLUC/NS 2 GM/100 ML,2500003678,CDM,250,RC,J0613,HCPCS,4456762124,NDC,,,,outpatient,facility,100,UN,156.42,156.42,0.09,548.68,,110.92,,,percent of total billed charges,,,38.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,156.42,,,percent of total billed charges,,,0.12,,,fee schedule,,,0.11,,,fee schedule,,,,,,,,,0.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,156.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,57.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,156.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,156.42,,,fee schedule,,,156.42,,,percent of total billed charges,,,,,,,,,156.42,,,percent of total billed charges,,,95.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,92.29,,,percent of total billed charges,,,548.68,,,per diem,,,156.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,156.42,,,percent of total billed charges,,,132.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,83.07,,,percent of total billed charges,,,156.42,,,percent of total billed charges,,,156.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.52,,,percent of total billed charges,,,126.58,,,percent of total billed charges,,,,,,,,,,,,,,,62.57,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,156.42,,,percent of total billed charges,,,156.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,156.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.51,,,percent of total billed charges,,,156.42,,,percent of total billed charges,,,,,,,,,,,,,,,156.42,,,percent of total billed charges,,,156.42,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.09,,,fee schedule,,,156.42,,,percent of total billed charges,,,156.42,,,percent of total billed charges,,,156.42,,,percent of total billed charges,,,,,,,,,109.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,92.16,,,percent of total billed charges,,
CALCIUM GLUC/NS 2 GM/100 ML,2500003678,CDM,250,RC,J0613,HCPCS,4456762124,NDC,999,EAPG,,outpatient,facility,100,UN,156.42,156.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCIUM GLUC/NS 1 GM/50 ML,2500003679,CDM,250,RC,J0613,HCPCS,4456762024,NDC,,,,inpatient,facility,50,UN,78.21,78.21,6.26,78.21,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,,,,,,,78.21,,,percent of total billed charges,,,39.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.93,,,percent of total billed charges,,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,66.48,,,percent of total billed charges,,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,41.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.08,,,percent of total billed charges,,
CALCIUM GLUC/NS 1 GM/50 ML,2500003679,CDM,250,RC,J0613,HCPCS,4456762024,NDC,,,,outpatient,facility,50,UN,78.21,78.21,0.09,548.68,,55.46,,,percent of total billed charges,,,19.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,78.21,,,percent of total billed charges,,,0.12,,,fee schedule,,,0.11,,,fee schedule,,,,,,,,,0.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,28.62,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,78.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,78.21,,,fee schedule,,,78.21,,,percent of total billed charges,,,,,,,,,78.21,,,percent of total billed charges,,,47.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,46.14,,,percent of total billed charges,,,548.68,,,per diem,,,78.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,78.21,,,percent of total billed charges,,,66.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.54,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.76,,,percent of total billed charges,,,63.29,,,percent of total billed charges,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,78.21,,,percent of total billed charges,,,78.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,78.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.26,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,78.21,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.09,,,fee schedule,,,78.21,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,,,,,,,54.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,46.08,,,percent of total billed charges,,
CALCIUM GLUC/NS 1 GM/50 ML,2500003679,CDM,250,RC,J0613,HCPCS,4456762024,NDC,999,EAPG,,outpatient,facility,50,UN,78.21,78.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL 50 MCG/ML INJ,2500003689,CDM,636,RC,J3010,HCPCS,6332380601,NDC,,,,inpatient,facility,1,UN,7.29,7.29,0.58,7.29,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,,,,,,,7.29,,,percent of total billed charges,,,3.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,6.2,,,percent of total billed charges,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,
FENTANYL 50 MCG/ML INJ,2500003689,CDM,636,RC,J3010,HCPCS,6332380601,NDC,,,,outpatient,facility,1,UN,7.29,7.29,0.38,548.68,,5.17,,,percent of total billed charges,,,1.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.29,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.67,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.38,,,fee schedule,,,7.29,,,fee schedule,,,7.29,,,percent of total billed charges,,,,,,,,,7.29,,,percent of total billed charges,,,4.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,4.3,,,percent of total billed charges,,,548.68,,,per diem,,,7.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.29,,,percent of total billed charges,,,6.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,5.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7.29,,,percent of total billed charges,,,7.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.58,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.87,,,fee schedule,,,7.29,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,,,,,,,5.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.65,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.3,,,percent of total billed charges,,
FENTANYL 50 MCG/ML INJ,2500003689,CDM,636,RC,J3010,HCPCS,6332380601,NDC,496,EAPG,,outpatient,facility,1,UN,7.29,7.29,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BLEOMYCIN SULF 15 UNITS GEN,2500003690,CDM,636,RC,J9040,HCPCS,7128810610,NDC,,,,inpatient,facility,15,UN,101.24,101.24,8.1,101.24,,,,,,,,,,,,,,101.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.24,,,percent of total billed charges,,,,,,,,,101.24,,,percent of total billed charges,,,51.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.74,,,percent of total billed charges,,,,,,,,,,,,,,,101.24,,,percent of total billed charges,,,86.05,,,percent of total billed charges,,,,,,,,,,,,,,,101.24,,,percent of total billed charges,,,53.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,101.24,,,percent of total billed charges,,,,,,,,,,,,,,,8.1,,,percent of total billed charges,,,101.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,101.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.65,,,percent of total billed charges,,
BLEOMYCIN SULF 15 UNITS GEN,2500003690,CDM,636,RC,J9040,HCPCS,7128810610,NDC,,,,outpatient,facility,15,UN,101.24,101.24,8.1,548.68,,23.12,,,fee schedule,,,24.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,101.24,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,101.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,37.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,27.99,,,fee schedule,,,101.24,,,fee schedule,,,101.24,,,percent of total billed charges,,,,,,,,,101.24,,,percent of total billed charges,,,62.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,59.73,,,percent of total billed charges,,,548.68,,,per diem,,,101.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,101.24,,,percent of total billed charges,,,86.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.77,,,percent of total billed charges,,,101.24,,,percent of total billed charges,,,101.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.3,,,percent of total billed charges,,,81.92,,,percent of total billed charges,,,,,,,,,,,,,,,40.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,101.24,,,percent of total billed charges,,,101.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,101.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.1,,,percent of total billed charges,,,101.24,,,percent of total billed charges,,,,,,,,,,,,,,,101.24,,,percent of total billed charges,,,101.24,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,26.08,,,fee schedule,,,101.24,,,percent of total billed charges,,,101.24,,,percent of total billed charges,,,101.24,,,percent of total billed charges,,,,,,,,,70.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.62,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,59.65,,,percent of total billed charges,,
BLEOMYCIN SULF 15 UNITS GEN,2500003690,CDM,636,RC,J9040,HCPCS,7128810610,NDC,430,EAPG,,outpatient,facility,15,UN,101.24,101.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BLEOMYCIN SULF 30 UNITS GEN,2500003692,CDM,636,RC,J9040,HCPCS,7128810720,NDC,,,,inpatient,facility,30,UN,220.08,220.08,17.61,220.08,,,,,,,,,,,,,,220.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.08,,,percent of total billed charges,,,,,,,,,220.08,,,percent of total billed charges,,,112.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.05,,,percent of total billed charges,,,,,,,,,,,,,,,220.08,,,percent of total billed charges,,,187.07,,,percent of total billed charges,,,,,,,,,,,,,,,220.08,,,percent of total billed charges,,,116.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,220.08,,,percent of total billed charges,,,,,,,,,,,,,,,17.61,,,percent of total billed charges,,,220.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,220.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.67,,,percent of total billed charges,,
BLEOMYCIN SULF 30 UNITS GEN,2500003692,CDM,636,RC,J9040,HCPCS,7128810720,NDC,,,,outpatient,facility,30,UN,220.08,220.08,17.61,548.68,,23.12,,,fee schedule,,,53.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,220.08,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,220.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,80.55,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,27.99,,,fee schedule,,,220.08,,,fee schedule,,,220.08,,,percent of total billed charges,,,,,,,,,220.08,,,percent of total billed charges,,,134.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,129.85,,,percent of total billed charges,,,548.68,,,per diem,,,220.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,220.08,,,percent of total billed charges,,,187.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,116.88,,,percent of total billed charges,,,220.08,,,percent of total billed charges,,,220.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.47,,,percent of total billed charges,,,178.09,,,percent of total billed charges,,,,,,,,,,,,,,,88.03,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,220.08,,,percent of total billed charges,,,220.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,220.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.61,,,percent of total billed charges,,,220.08,,,percent of total billed charges,,,,,,,,,,,,,,,220.08,,,percent of total billed charges,,,220.08,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,26.08,,,fee schedule,,,220.08,,,percent of total billed charges,,,220.08,,,percent of total billed charges,,,220.08,,,percent of total billed charges,,,,,,,,,154.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,129.67,,,percent of total billed charges,,
BLEOMYCIN SULF 30 UNITS GEN,2500003692,CDM,636,RC,J9040,HCPCS,7128810720,NDC,430,EAPG,,outpatient,facility,30,UN,220.08,220.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 2  VISC SOLN 5 ML IN,2500003697,CDM,637,RC,527600274,NDC,,,,,,inpatient,facility,5,UN,2.18,2.18,0.17,2.18,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,
LIDOCAINE 2  VISC SOLN 5 ML IN,2500003697,CDM,637,RC,527600274,NDC,,,,,,outpatient,facility,5,UN,2.18,2.18,0.17,548.68,,1.55,,,percent of total billed charges,,,0.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.18,,,percent of total billed charges,,,1.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.8,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.18,,,fee schedule,,,2.18,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,548.68,,,per diem,,,2.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.18,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,0.81,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.28,,,percent of total billed charges,,
LIDOCAINE 2  VISC SOLN 5 ML IN,2500003697,CDM,637,RC,527600274,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.18,2.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBOPLATIN 50 MG INJ,2500003704,CDM,636,RC,J9045,HCPCS,6332317260,NDC,,,,inpatient,facility,50,UN,32.67,32.67,2.61,32.67,,,,,,,,,,,,,,32.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.67,,,percent of total billed charges,,,,,,,,,32.67,,,percent of total billed charges,,,16.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.6,,,percent of total billed charges,,,,,,,,,,,,,,,32.67,,,percent of total billed charges,,,27.77,,,percent of total billed charges,,,,,,,,,,,,,,,32.67,,,percent of total billed charges,,,17.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,32.67,,,percent of total billed charges,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,32.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.25,,,percent of total billed charges,,
CARBOPLATIN 50 MG INJ,2500003704,CDM,636,RC,J9045,HCPCS,6332317260,NDC,,,,outpatient,facility,50,UN,32.67,32.67,2.61,548.68,,3.72,,,fee schedule,,,7.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,32.67,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,32.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.96,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.7,,,fee schedule,,,32.67,,,fee schedule,,,32.67,,,percent of total billed charges,,,,,,,,,32.67,,,percent of total billed charges,,,20.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,19.28,,,percent of total billed charges,,,548.68,,,per diem,,,32.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,32.67,,,percent of total billed charges,,,27.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.35,,,percent of total billed charges,,,32.67,,,percent of total billed charges,,,32.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.04,,,percent of total billed charges,,,26.44,,,percent of total billed charges,,,,,,,,,,,,,,,13.07,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,32.67,,,percent of total billed charges,,,32.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,32.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.61,,,percent of total billed charges,,,32.67,,,percent of total billed charges,,,,,,,,,,,,,,,32.67,,,percent of total billed charges,,,32.67,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.83,,,fee schedule,,,32.67,,,percent of total billed charges,,,32.67,,,percent of total billed charges,,,32.67,,,percent of total billed charges,,,,,,,,,22.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,19.25,,,percent of total billed charges,,
CARBOPLATIN 50 MG INJ,2500003704,CDM,636,RC,J9045,HCPCS,6332317260,NDC,430,EAPG,,outpatient,facility,50,UN,32.67,32.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUTICASONE/SALM 113/14MCG INH,2500003713,CDM,637,RC,93360882,NDC,,,,,,inpatient,facility,8,UN,506.29,506.29,40.5,506.29,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,506.29,,,percent of total billed charges,,,258.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,431.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.77,,,percent of total billed charges,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,430.35,,,percent of total billed charges,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,268.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,40.5,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.31,,,percent of total billed charges,,
FLUTICASONE/SALM 113/14MCG INH,2500003713,CDM,637,RC,93360882,NDC,,,,,,outpatient,facility,8,UN,506.29,506.29,40.5,548.68,,359.01,,,percent of total billed charges,,,123.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,506.29,,,percent of total billed charges,,,317.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,355.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,355.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,185.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,506.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,506.29,,,fee schedule,,,506.29,,,percent of total billed charges,,,,,,,,,506.29,,,percent of total billed charges,,,310.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.73,,,percent of total billed charges,,,,,,,,,,,,,,,273.4,,,percent of total billed charges,,,263.27,,,percent of total billed charges,,,278.46,,,percent of total billed charges,,,,,,,,,298.71,,,percent of total billed charges,,,548.68,,,per diem,,,506.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,506.29,,,percent of total billed charges,,,430.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,268.89,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,341.54,,,percent of total billed charges,,,409.69,,,percent of total billed charges,,,,,,,,,,,,,,,202.52,,,percent of total billed charges,,,,,,,,,187.33,,,percent of total billed charges,,,187.33,,,percent of total billed charges,,,,,,,,,506.29,,,percent of total billed charges,,,506.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,506.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.5,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,470.95,,,percent of total billed charges,,,,,,,,,,,,,,,470.95,,,percent of total billed charges,,,470.95,,,percent of total billed charges,,,470.95,,,percent of total billed charges,,,379.72,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,298.31,,,percent of total billed charges,,
FLUTICASONE/SALM 113/14MCG INH,2500003713,CDM,637,RC,93360882,NDC,999,EAPG,,,,outpatient,facility,8,UN,506.29,506.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUTICASONE/SALM 232/14MCG INH,2500003715,CDM,637,RC,93360982,NDC,,,,,,inpatient,facility,8,UN,506.29,506.29,40.5,506.29,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,506.29,,,percent of total billed charges,,,258.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,431.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.77,,,percent of total billed charges,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,430.35,,,percent of total billed charges,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,268.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,40.5,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.31,,,percent of total billed charges,,
FLUTICASONE/SALM 232/14MCG INH,2500003715,CDM,637,RC,93360982,NDC,,,,,,outpatient,facility,8,UN,506.29,506.29,40.5,548.68,,359.01,,,percent of total billed charges,,,123.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,506.29,,,percent of total billed charges,,,317.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,355.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,355.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,185.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,506.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,506.29,,,fee schedule,,,506.29,,,percent of total billed charges,,,,,,,,,506.29,,,percent of total billed charges,,,310.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.73,,,percent of total billed charges,,,,,,,,,,,,,,,273.4,,,percent of total billed charges,,,263.27,,,percent of total billed charges,,,278.46,,,percent of total billed charges,,,,,,,,,298.71,,,percent of total billed charges,,,548.68,,,per diem,,,506.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,506.29,,,percent of total billed charges,,,430.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,268.89,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,341.54,,,percent of total billed charges,,,409.69,,,percent of total billed charges,,,,,,,,,,,,,,,202.52,,,percent of total billed charges,,,,,,,,,187.33,,,percent of total billed charges,,,187.33,,,percent of total billed charges,,,,,,,,,506.29,,,percent of total billed charges,,,506.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,506.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.5,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,,,,,,,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,470.95,,,percent of total billed charges,,,,,,,,,,,,,,,470.95,,,percent of total billed charges,,,470.95,,,percent of total billed charges,,,470.95,,,percent of total billed charges,,,379.72,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,506.29,,,percent of total billed charges,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,298.31,,,percent of total billed charges,,
FLUTICASONE/SALM 232/14MCG INH,2500003715,CDM,637,RC,93360982,NDC,999,EAPG,,,,outpatient,facility,8,UN,506.29,506.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUTICASONE FURO 200MCG 14 INH,2500003716,CDM,637,RC,173087614,NDC,,,,,,inpatient,facility,14,UN,30.69,30.69,2.46,30.69,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,,,,,,,30.69,,,percent of total billed charges,,,15.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.41,,,percent of total billed charges,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,26.09,,,percent of total billed charges,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,16.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.08,,,percent of total billed charges,,
FLUTICASONE FURO 200MCG 14 INH,2500003716,CDM,637,RC,173087614,NDC,,,,,,outpatient,facility,14,UN,30.69,30.69,2.46,548.68,,21.76,,,percent of total billed charges,,,7.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,30.69,,,percent of total billed charges,,,19.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,21.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,21.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,30.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,30.69,,,fee schedule,,,30.69,,,percent of total billed charges,,,,,,,,,30.69,,,percent of total billed charges,,,18.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.87,,,percent of total billed charges,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,15.96,,,percent of total billed charges,,,16.88,,,percent of total billed charges,,,,,,,,,18.11,,,percent of total billed charges,,,548.68,,,per diem,,,30.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,30.69,,,percent of total billed charges,,,26.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.3,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.7,,,percent of total billed charges,,,24.83,,,percent of total billed charges,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,,,,,,,11.36,,,percent of total billed charges,,,11.36,,,percent of total billed charges,,,,,,,,,30.69,,,percent of total billed charges,,,30.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.46,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,,,,,,,28.55,,,percent of total billed charges,,,,,,,,,,,,,,,28.55,,,percent of total billed charges,,,28.55,,,percent of total billed charges,,,28.55,,,percent of total billed charges,,,23.02,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,30.69,,,percent of total billed charges,,,,,,,,,21.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.08,,,percent of total billed charges,,
FLUTICASONE FURO 200MCG 14 INH,2500003716,CDM,637,RC,173087614,NDC,999,EAPG,,,,outpatient,facility,14,UN,30.69,30.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUTICASONE FURO 100MCG 14 INH,2500003717,CDM,637,RC,173087410,NDC,,,,,,inpatient,facility,14,UN,22.94,22.94,1.84,22.94,,,,,,,,,,,,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.94,,,percent of total billed charges,,,,,,,,,22.94,,,percent of total billed charges,,,11.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,22.94,,,percent of total billed charges,,,19.5,,,percent of total billed charges,,,,,,,,,,,,,,,22.94,,,percent of total billed charges,,,12.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.52,,,percent of total billed charges,,
FLUTICASONE FURO 100MCG 14 INH,2500003717,CDM,637,RC,173087410,NDC,,,,,,outpatient,facility,14,UN,22.94,22.94,1.84,548.68,,16.27,,,percent of total billed charges,,,5.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,22.94,,,percent of total billed charges,,,14.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,16.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,16.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,22.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,22.94,,,fee schedule,,,22.94,,,percent of total billed charges,,,,,,,,,22.94,,,percent of total billed charges,,,14.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.34,,,percent of total billed charges,,,,,,,,,,,,,,,12.39,,,percent of total billed charges,,,11.93,,,percent of total billed charges,,,12.62,,,percent of total billed charges,,,,,,,,,13.53,,,percent of total billed charges,,,548.68,,,per diem,,,22.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,22.94,,,percent of total billed charges,,,19.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.18,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.48,,,percent of total billed charges,,,18.56,,,percent of total billed charges,,,,,,,,,,,,,,,9.18,,,percent of total billed charges,,,,,,,,,8.49,,,percent of total billed charges,,,8.49,,,percent of total billed charges,,,,,,,,,22.94,,,percent of total billed charges,,,22.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.84,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,22.94,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,,,,,,,21.34,,,percent of total billed charges,,,,,,,,,,,,,,,21.34,,,percent of total billed charges,,,21.34,,,percent of total billed charges,,,21.34,,,percent of total billed charges,,,17.21,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,,,,,,,16.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.52,,,percent of total billed charges,,
FLUTICASONE FURO 100MCG 14 INH,2500003717,CDM,637,RC,173087410,NDC,999,EAPG,,,,outpatient,facility,14,UN,22.94,22.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
UMECLIDINIUM 62.5 MCG 1 PUFF,2500003719,CDM,637,RC,173087310,NDC,,,,,,inpatient,facility,1,UN,38.94,38.94,3.12,38.94,,,,,,,,,,,,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.94,,,percent of total billed charges,,,,,,,,,38.94,,,percent of total billed charges,,,19.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,38.94,,,percent of total billed charges,,,33.1,,,percent of total billed charges,,,,,,,,,,,,,,,38.94,,,percent of total billed charges,,,20.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.94,,,percent of total billed charges,,
UMECLIDINIUM 62.5 MCG 1 PUFF,2500003719,CDM,637,RC,173087310,NDC,,,,,,outpatient,facility,1,UN,38.94,38.94,3.12,548.68,,27.61,,,percent of total billed charges,,,9.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,38.94,,,percent of total billed charges,,,24.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,27.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,27.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,14.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,38.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,38.94,,,fee schedule,,,38.94,,,percent of total billed charges,,,,,,,,,38.94,,,percent of total billed charges,,,23.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.74,,,percent of total billed charges,,,,,,,,,,,,,,,21.03,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,21.42,,,percent of total billed charges,,,,,,,,,22.97,,,percent of total billed charges,,,548.68,,,per diem,,,38.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,38.94,,,percent of total billed charges,,,33.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.68,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.27,,,percent of total billed charges,,,31.51,,,percent of total billed charges,,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,,,,,,,14.41,,,percent of total billed charges,,,14.41,,,percent of total billed charges,,,,,,,,,38.94,,,percent of total billed charges,,,38.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,38.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.12,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,,,,,,,,,,,,,38.94,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,,,,,,,36.22,,,percent of total billed charges,,,,,,,,,,,,,,,36.22,,,percent of total billed charges,,,36.22,,,percent of total billed charges,,,36.22,,,percent of total billed charges,,,29.2,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,38.94,,,percent of total billed charges,,,,,,,,,27.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,22.94,,,percent of total billed charges,,
UMECLIDINIUM 62.5 MCG 1 PUFF,2500003719,CDM,637,RC,173087310,NDC,999,EAPG,,,,outpatient,facility,1,UN,38.94,38.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CISPLATIN INJ 10 MG,2500003720,CDM,636,RC,J9060,HCPCS,1672928811,NDC,,,,inpatient,facility,10,UN,14.85,14.85,1.19,14.85,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,,,,,,,14.85,,,percent of total billed charges,,,7.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,12.62,,,percent of total billed charges,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.75,,,percent of total billed charges,,
CISPLATIN INJ 10 MG,2500003720,CDM,636,RC,J9060,HCPCS,1672928811,NDC,,,,outpatient,facility,10,UN,14.85,14.85,1.19,548.68,,3.27,,,fee schedule,,,3.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.55,,,fee schedule,,,14.85,,,fee schedule,,,14.85,,,percent of total billed charges,,,,,,,,,14.85,,,percent of total billed charges,,,9.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,8.76,,,percent of total billed charges,,,548.68,,,per diem,,,14.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.85,,,percent of total billed charges,,,12.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.02,,,percent of total billed charges,,,12.02,,,percent of total billed charges,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,14.85,,,percent of total billed charges,,,14.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.19,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.88,,,fee schedule,,,14.85,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,,,,,,,10.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.75,,,percent of total billed charges,,
CISPLATIN INJ 10 MG,2500003720,CDM,636,RC,J9060,HCPCS,1672928811,NDC,495,EAPG,,outpatient,facility,10,UN,14.85,14.85,21.18,31.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.98,,,fee schedule,,,21.18,,,fee schedule,,,28.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,21.18,,,fee schedule,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
UMECLIDINIUM/VILANTEROL 1 PUFF,2500003721,CDM,637,RC,173086910,NDC,,,,,,inpatient,facility,1,UN,25.34,25.34,2.03,25.34,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,,,,,,,25.34,,,percent of total billed charges,,,12.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,21.54,,,percent of total billed charges,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.93,,,percent of total billed charges,,
UMECLIDINIUM/VILANTEROL 1 PUFF,2500003721,CDM,637,RC,173086910,NDC,,,,,,outpatient,facility,1,UN,25.34,25.34,2.03,548.68,,17.97,,,percent of total billed charges,,,6.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,25.34,,,percent of total billed charges,,,15.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,17.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,17.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.27,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,25.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,25.34,,,fee schedule,,,25.34,,,percent of total billed charges,,,,,,,,,25.34,,,percent of total billed charges,,,15.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,13.68,,,percent of total billed charges,,,13.18,,,percent of total billed charges,,,13.94,,,percent of total billed charges,,,,,,,,,14.95,,,percent of total billed charges,,,548.68,,,per diem,,,25.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,25.34,,,percent of total billed charges,,,21.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.09,,,percent of total billed charges,,,20.51,,,percent of total billed charges,,,,,,,,,,,,,,,10.14,,,percent of total billed charges,,,,,,,,,9.38,,,percent of total billed charges,,,9.38,,,percent of total billed charges,,,,,,,,,25.34,,,percent of total billed charges,,,25.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.03,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,,,,,,,23.57,,,percent of total billed charges,,,,,,,,,,,,,,,23.57,,,percent of total billed charges,,,23.57,,,percent of total billed charges,,,23.57,,,percent of total billed charges,,,19,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,,,,,,,17.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.67,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.93,,,percent of total billed charges,,
UMECLIDINIUM/VILANTEROL 1 PUFF,2500003721,CDM,637,RC,173086910,NDC,999,EAPG,,,,outpatient,facility,1,UN,25.34,25.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ONDANSETRON HCL ORAL 4MG,2500003730,CDM,637,RC,904655161,NDC,,,,,,inpatient,facility,4,UN,1.65,1.65,0.13,1.65,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,1.65,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,,percent of total billed charges,,
ONDANSETRON HCL ORAL 4MG,2500003730,CDM,637,RC,904655161,NDC,,,,,,outpatient,facility,4,UN,1.65,1.65,0.13,548.68,,1.17,,,percent of total billed charges,,,0.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.65,,,percent of total billed charges,,,1.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.6,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.65,,,fee schedule,,,1.65,,,percent of total billed charges,,,,,,,,,1.65,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,0.97,,,percent of total billed charges,,,548.68,,,per diem,,,1.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.65,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,0.61,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,,,,,,,1.65,,,percent of total billed charges,,,1.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.97,,,percent of total billed charges,,
ONDANSETRON HCL ORAL 4MG,2500003730,CDM,637,RC,904655161,NDC,999,EAPG,,,,outpatient,facility,4,UN,1.65,1.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIRSEVIMAB-ALIP 50MG/0.5ML STA,2500003735,CDM,636,RC,90380,CPT,,,,,,inpatient,facility,,,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
NIRSEVIMAB-ALIP 50MG/0.5ML STA,2500003735,CDM,636,RC,90380,CPT,,,,,,outpatient,facility,,,0.01,0.01,0.01,769.09,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,769.09,,,fee schedule,,,727.61,,,fee schedule,,,,,,,,,727.61,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
NIRSEVIMAB-ALIP 50MG/0.5ML STA,2500003735,CDM,636,RC,90380,CPT,444,EAPG,,,,outpatient,facility,,,0.01,0.01,1304.36,1969.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1969.58,,,fee schedule,,,1304.36,,,fee schedule,,,1750.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIRSVIMAB-ALIP 100MG/ML STATE,2500003737,CDM,636,RC,90381,CPT,,,,,,inpatient,facility,,,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
NIRSVIMAB-ALIP 100MG/ML STATE,2500003737,CDM,636,RC,90381,CPT,,,,,,outpatient,facility,,,0.01,0.01,0.01,769.09,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,769.09,,,fee schedule,,,727.61,,,fee schedule,,,,,,,,,727.61,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
NIRSVIMAB-ALIP 100MG/ML STATE,2500003737,CDM,636,RC,90381,CPT,444,EAPG,,,,outpatient,facility,,,0.01,0.01,1304.36,1969.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1969.58,,,fee schedule,,,1304.36,,,fee schedule,,,1750.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBOXYMETHYLCELLULOSE SODIUM,2500003747,CDM,637,RC,23079815,NDC,,,,,,inpatient,facility,15,UN,27.69,27.69,2.22,27.69,,,,,,,,,,,,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.69,,,percent of total billed charges,,,,,,,,,27.69,,,percent of total billed charges,,,14.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.61,,,percent of total billed charges,,,,,,,,,,,,,,,27.69,,,percent of total billed charges,,,23.54,,,percent of total billed charges,,,,,,,,,,,,,,,27.69,,,percent of total billed charges,,,14.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.31,,,percent of total billed charges,,
CARBOXYMETHYLCELLULOSE SODIUM,2500003747,CDM,637,RC,23079815,NDC,,,,,,outpatient,facility,15,UN,27.69,27.69,2.22,548.68,,19.63,,,percent of total billed charges,,,6.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,27.69,,,percent of total billed charges,,,17.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,19.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,19.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.13,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,27.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,27.69,,,fee schedule,,,27.69,,,percent of total billed charges,,,,,,,,,27.69,,,percent of total billed charges,,,16.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.73,,,percent of total billed charges,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,15.23,,,percent of total billed charges,,,,,,,,,16.34,,,percent of total billed charges,,,548.68,,,per diem,,,27.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,27.69,,,percent of total billed charges,,,23.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.71,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.68,,,percent of total billed charges,,,22.41,,,percent of total billed charges,,,,,,,,,,,,,,,11.08,,,percent of total billed charges,,,,,,,,,10.25,,,percent of total billed charges,,,10.25,,,percent of total billed charges,,,,,,,,,27.69,,,percent of total billed charges,,,27.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.22,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,27.69,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,,,,,,,25.76,,,percent of total billed charges,,,,,,,,,,,,,,,25.76,,,percent of total billed charges,,,25.76,,,percent of total billed charges,,,25.76,,,percent of total billed charges,,,20.77,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,27.69,,,percent of total billed charges,,,,,,,,,19.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,16.31,,,percent of total billed charges,,
CARBOXYMETHYLCELLULOSE SODIUM,2500003747,CDM,637,RC,23079815,NDC,999,EAPG,,,,outpatient,facility,15,UN,27.69,27.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Nirmatlvir/Ritonvir150-100 TAB,2500003753,CDM,637,RC,69108506,NDC,,,,,,inpatient,facility,1,UN,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
Nirmatlvir/Ritonvir150-100 TAB,2500003753,CDM,637,RC,69108506,NDC,,,,,,outpatient,facility,1,UN,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
Nirmatlvir/Ritonvir150-100 TAB,2500003753,CDM,637,RC,69108506,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.01,0.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMINO ACIDS 5 /D15W 2000 ML B,2500003756,CDM,258,RC,338109904,NDC,,,,,,inpatient,facility,2000,UN,265.32,265.32,21.23,265.32,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,265.32,,,percent of total billed charges,,,135.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,225.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.19,,,percent of total billed charges,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,225.52,,,percent of total billed charges,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,140.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,21.23,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.33,,,percent of total billed charges,,
AMINO ACIDS 5 /D15W 2000 ML B,2500003756,CDM,258,RC,338109904,NDC,,,,,,outpatient,facility,2000,UN,265.32,265.32,21.23,548.68,,188.14,,,percent of total billed charges,,,64.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,265.32,,,percent of total billed charges,,,166.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,186.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,186.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,97.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,265.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,265.32,,,fee schedule,,,265.32,,,percent of total billed charges,,,,,,,,,265.32,,,percent of total billed charges,,,162.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,156.54,,,percent of total billed charges,,,548.68,,,per diem,,,265.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,265.32,,,percent of total billed charges,,,225.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.91,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.98,,,percent of total billed charges,,,214.7,,,percent of total billed charges,,,,,,,,,,,,,,,106.13,,,percent of total billed charges,,,,,,,,,106.13,,,percent of total billed charges,,,106.13,,,percent of total billed charges,,,,,,,,,265.32,,,percent of total billed charges,,,265.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,265.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.23,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,106.13,,,percent of total billed charges,,,,,,,,,,,,,,,106.13,,,percent of total billed charges,,,106.13,,,percent of total billed charges,,,106.13,,,percent of total billed charges,,,198.99,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,186.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,156.33,,,percent of total billed charges,,
AMINO ACIDS 5 /D15W 2000 ML B,2500003756,CDM,258,RC,338109904,NDC,999,EAPG,,,,outpatient,facility,2000,UN,265.32,265.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CYCLOPHOSPHAMIDE INJ 100 MG,2500003760,CDM,636,RC,J9075,HCPCS,7012112391,NDC,,,,inpatient,facility,100,GR,241.72,241.72,19.34,241.72,,,,,,,,,,,,,,241.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.72,,,percent of total billed charges,,,,,,,,,241.72,,,percent of total billed charges,,,123.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.03,,,percent of total billed charges,,,,,,,,,,,,,,,241.72,,,percent of total billed charges,,,205.46,,,percent of total billed charges,,,,,,,,,,,,,,,241.72,,,percent of total billed charges,,,128.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,241.72,,,percent of total billed charges,,,,,,,,,,,,,,,19.34,,,percent of total billed charges,,,241.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,241.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.42,,,percent of total billed charges,,
CYCLOPHOSPHAMIDE INJ 100 MG,2500003760,CDM,636,RC,J9075,HCPCS,7012112391,NDC,,,,outpatient,facility,100,GR,241.72,241.72,1.14,548.68,,171.4,,,percent of total billed charges,,,,,,,,,241.72,,,percent of total billed charges,,,1.44,,,fee schedule,,,1.36,,,fee schedule,,,,,,,,,1.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,241.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,241.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,241.72,,,fee schedule,,,241.72,,,percent of total billed charges,,,,,,,,,241.72,,,percent of total billed charges,,,148.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.23,,,percent of total billed charges,,,,,,,,,,,,,,,130.53,,,percent of total billed charges,,,125.69,,,percent of total billed charges,,,132.95,,,percent of total billed charges,,,,,,,,,142.61,,,percent of total billed charges,,,548.68,,,per diem,,,241.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,241.72,,,percent of total billed charges,,,205.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,128.38,,,percent of total billed charges,,,241.72,,,percent of total billed charges,,,241.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.06,,,percent of total billed charges,,,195.6,,,percent of total billed charges,,,,,,,,,,,,,,,96.69,,,percent of total billed charges,,,,,,,,,89.44,,,percent of total billed charges,,,89.44,,,percent of total billed charges,,,,,,,,,241.72,,,percent of total billed charges,,,,,,,,,,,,,,,19.34,,,percent of total billed charges,,,241.72,,,percent of total billed charges,,,,,,,,,,,,,,,241.72,,,percent of total billed charges,,,241.72,,,percent of total billed charges,,,,,,,,,224.85,,,percent of total billed charges,,,,,,,,,,,,,,,224.85,,,percent of total billed charges,,,224.85,,,percent of total billed charges,,,224.85,,,percent of total billed charges,,,1.14,,,fee schedule,,,241.72,,,percent of total billed charges,,,241.72,,,percent of total billed charges,,,241.72,,,percent of total billed charges,,,,,,,,,169.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.86,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,142.42,,,percent of total billed charges,,
CYCLOPHOSPHAMIDE INJ 100 MG,2500003760,CDM,636,RC,J9075,HCPCS,7012112391,NDC,743,APC,,outpatient,facility,100,GR,241.72,241.72,0.84,88.47,,,,,,,,0.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,fee schedule,,,,,,,,,88.47,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,fee schedule,,,,,,,,,,,,,,,0.92,,,fee schedule,,,0.92,,,fee schedule,,,,,,,,,0.88,,,fee schedule,,,0.88,,,fee schedule,,,0.92,,,fee schedule,,,,,,,,,,,,,,,1.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,fee schedule,,,0.94,,,fee schedule,,,0.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,fee schedule,,,0.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,fee schedule,,,,,,,,,1.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.88,,,fee schedule,,,0.88,,,fee schedule,,,,,,,,,,,,,,,0.88,,,fee schedule,,,,,,,,,0.88,,,fee schedule,,,0.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,fee schedule,,,,,,,,,,,,,,,0.92,,,fee schedule,,,0.88,,,fee schedule,,,,,,,,,0.88,,,fee schedule,,,,,,,,,0.88,,,fee schedule,,,0.92,,,fee schedule,,,,,,,,
CYCLOPHOSPHAMIDE INJ 100 MG,2500003760,CDM,636,RC,J9075,HCPCS,7012112391,NDC,432,EAPG,,outpatient,facility,100,GR,241.72,241.72,148.29,223.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.92,,,fee schedule,,,148.29,,,fee schedule,,,199.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.29,,,fee schedule,,,148.29,,,fee schedule,,,148.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,148.29,,,fee schedule,,,,,,,,,,,,,,,148.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RSVPREF3 ANTIGN/AS01E/PF120 SS,2500003766,CDM,636,RC,90679,CPT,,,,,,inpatient,facility,,,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
RSVPREF3 ANTIGN/AS01E/PF120 SS,2500003766,CDM,636,RC,90679,CPT,,,,,,outpatient,facility,,,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,436.13,,,fee schedule,,,412.61,,,fee schedule,,,,,,,,,412.61,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
RSVPREF3 ANTIGN/AS01E/PF120 SS,2500003766,CDM,636,RC,90679,CPT,414,EAPG,,,,outpatient,facility,,,0.01,0.01,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RSV VACCPREF A &PREF B/PF SS,2500003767,CDM,636,RC,90678,CPT,,,,,,inpatient,facility,,,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
RSV VACCPREF A &PREF B/PF SS,2500003767,CDM,636,RC,90678,CPT,,,,,,outpatient,facility,,,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,459.49,,,fee schedule,,,434.71,,,fee schedule,,,,,,,,,434.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
RSV VACCPREF A &PREF B/PF SS,2500003767,CDM,636,RC,90678,CPT,414,EAPG,,,,outpatient,facility,,,0.01,0.01,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PCC (BALFAXAR) 1000 UNIT VIAL,2500003777,CDM,636,RC,J7165,HCPCS,6898226102,NDC,,,,inpatient,facility,40,UN,4550.83,4550.83,364.07,4550.83,,,,,,,,,,,,,,4550.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4550.83,,,percent of total billed charges,,,,,,,,,4550.83,,,percent of total billed charges,,,2323.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3875.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2730.5,,,percent of total billed charges,,,,,,,,,,,,,,,4550.83,,,percent of total billed charges,,,3868.21,,,percent of total billed charges,,,,,,,,,,,,,,,4550.83,,,percent of total billed charges,,,2416.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1820.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4550.83,,,percent of total billed charges,,,,,,,,,,,,,,,364.07,,,percent of total billed charges,,,4550.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4550.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2681.35,,,percent of total billed charges,,
PCC (BALFAXAR) 1000 UNIT VIAL,2500003777,CDM,636,RC,J7165,HCPCS,6898226102,NDC,,,,outpatient,facility,40,UN,4550.83,4550.83,4.41,4550.83,,3226.99,,,percent of total billed charges,,,,,,,,,4550.83,,,percent of total billed charges,,,4.66,,,fee schedule,,,4.41,,,fee schedule,,,,,,,,,4.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4550.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4550.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4550.83,,,fee schedule,,,4550.83,,,percent of total billed charges,,,,,,,,,4550.83,,,percent of total billed charges,,,2789.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3242.47,,,percent of total billed charges,,,,,,,,,,,,,,,2457.45,,,percent of total billed charges,,,2366.43,,,percent of total billed charges,,,2502.96,,,percent of total billed charges,,,,,,,,,2684.99,,,percent of total billed charges,,,548.68,,,per diem,,,4550.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4550.83,,,percent of total billed charges,,,3868.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2416.95,,,percent of total billed charges,,,4550.83,,,percent of total billed charges,,,4550.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3069.99,,,percent of total billed charges,,,3682.53,,,percent of total billed charges,,,,,,,,,,,,,,,1820.33,,,percent of total billed charges,,,,,,,,,1683.81,,,percent of total billed charges,,,1683.81,,,percent of total billed charges,,,,,,,,,4550.83,,,percent of total billed charges,,,,,,,,,,,,,,,364.07,,,percent of total billed charges,,,4550.83,,,percent of total billed charges,,,,,,,,,,,,,,,4550.83,,,percent of total billed charges,,,4550.83,,,percent of total billed charges,,,,,,,,,4233.18,,,percent of total billed charges,,,,,,,,,,,,,,,4233.18,,,percent of total billed charges,,,4233.18,,,percent of total billed charges,,,4233.18,,,percent of total billed charges,,,3413.12,,,percent of total billed charges,,,4550.83,,,percent of total billed charges,,,4550.83,,,percent of total billed charges,,,4550.83,,,percent of total billed charges,,,,,,,,,3190.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2275.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2681.35,,,percent of total billed charges,,
PCC (BALFAXAR) 1000 UNIT VIAL,2500003777,CDM,636,RC,J7165,HCPCS,6898226102,NDC,702,APC,,outpatient,facility,40,UN,4550.83,4550.83,1.73,1665.6,,,,,,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,fee schedule,,,,,,,,,1665.6,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,1.89,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,1.8,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,,,,,,,,2.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,fee schedule,,,1.93,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,1.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,2.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,1.8,,,fee schedule,,,1.8,,,fee schedule,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,1.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,1.87,,,fee schedule,,,1.8,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,
PCC (BALFAXAR) 1000 UNIT VIAL,2500003777,CDM,636,RC,J7165,HCPCS,6898226102,NDC,461,EAPG,,outpatient,facility,40,UN,4550.83,4550.83,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PCC (BALFAXAR) 500 UNIT VIAL,2500003778,CDM,636,RC,J7165,HCPCS,6898226101,NDC,,,,inpatient,facility,20,UN,2362.93,2362.93,189.03,2362.93,,,,,,,,,,,,,,2362.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2362.93,,,percent of total billed charges,,,,,,,,,2362.93,,,percent of total billed charges,,,1206.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2012.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1417.76,,,percent of total billed charges,,,,,,,,,,,,,,,2362.93,,,percent of total billed charges,,,2008.49,,,percent of total billed charges,,,,,,,,,,,,,,,2362.93,,,percent of total billed charges,,,1254.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2362.93,,,percent of total billed charges,,,,,,,,,,,,,,,189.03,,,percent of total billed charges,,,2362.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2362.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1392.24,,,percent of total billed charges,,
PCC (BALFAXAR) 500 UNIT VIAL,2500003778,CDM,636,RC,J7165,HCPCS,6898226101,NDC,,,,outpatient,facility,20,UN,2362.93,2362.93,4.41,2362.93,,1675.55,,,percent of total billed charges,,,,,,,,,2362.93,,,percent of total billed charges,,,4.66,,,fee schedule,,,4.41,,,fee schedule,,,,,,,,,4.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2362.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2362.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2362.93,,,fee schedule,,,2362.93,,,percent of total billed charges,,,,,,,,,2362.93,,,percent of total billed charges,,,1448.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1683.59,,,percent of total billed charges,,,,,,,,,,,,,,,1275.98,,,percent of total billed charges,,,1228.72,,,percent of total billed charges,,,1299.61,,,percent of total billed charges,,,,,,,,,1394.13,,,percent of total billed charges,,,548.68,,,per diem,,,2362.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2362.93,,,percent of total billed charges,,,2008.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1254.95,,,percent of total billed charges,,,2362.93,,,percent of total billed charges,,,2362.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1594.03,,,percent of total billed charges,,,1912.08,,,percent of total billed charges,,,,,,,,,,,,,,,945.17,,,percent of total billed charges,,,,,,,,,874.28,,,percent of total billed charges,,,874.28,,,percent of total billed charges,,,,,,,,,2362.93,,,percent of total billed charges,,,,,,,,,,,,,,,189.03,,,percent of total billed charges,,,2362.93,,,percent of total billed charges,,,,,,,,,,,,,,,2362.93,,,percent of total billed charges,,,2362.93,,,percent of total billed charges,,,,,,,,,2198,,,percent of total billed charges,,,,,,,,,,,,,,,2198,,,percent of total billed charges,,,2198,,,percent of total billed charges,,,2198,,,percent of total billed charges,,,1772.2,,,percent of total billed charges,,,2362.93,,,percent of total billed charges,,,2362.93,,,percent of total billed charges,,,2362.93,,,percent of total billed charges,,,,,,,,,1656.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1181.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1392.24,,,percent of total billed charges,,
PCC (BALFAXAR) 500 UNIT VIAL,2500003778,CDM,636,RC,J7165,HCPCS,6898226101,NDC,702,APC,,outpatient,facility,20,UN,2362.93,2362.93,1.73,864.83,,,,,,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,fee schedule,,,,,,,,,864.83,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,1.89,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,1.8,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,,,,,,,,2.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,fee schedule,,,1.93,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,1.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,2.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,1.8,,,fee schedule,,,1.8,,,fee schedule,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,1.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,1.87,,,fee schedule,,,1.8,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,
PCC (BALFAXAR) 500 UNIT VIAL,2500003778,CDM,636,RC,J7165,HCPCS,6898226101,NDC,461,EAPG,,outpatient,facility,20,UN,2362.93,2362.93,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PERTUZUMAB-TRASTMAB-HY-ZZXF 10,2500003808,CDM,636,RC,J9316,HCPCS,5024226001,NDC,,,,inpatient,facility,10,ML,29296.81,29296.81,2343.74,29296.81,,,,,,,,,,,,,,29296.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29296.81,,,percent of total billed charges,,,,,,,,,29296.81,,,percent of total billed charges,,,14958.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24952.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17578.09,,,percent of total billed charges,,,,,,,,,,,,,,,29296.81,,,percent of total billed charges,,,24902.29,,,percent of total billed charges,,,,,,,,,,,,,,,29296.81,,,percent of total billed charges,,,15559.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11718.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,29296.81,,,percent of total billed charges,,,,,,,,,,,,,,,2343.74,,,percent of total billed charges,,,29296.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29296.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17261.68,,,percent of total billed charges,,
PERTUZUMAB-TRASTMAB-HY-ZZXF 10,2500003808,CDM,636,RC,J9316,HCPCS,5024226001,NDC,,,,outpatient,facility,10,ML,29296.81,29296.81,47.67,29296.81,,65.32,,,fee schedule,,,,,,,,,29296.81,,,percent of total billed charges,,,86.08,,,fee schedule,,,81.44,,,fee schedule,,,,,,,,,81.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,29296.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,29296.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,29296.81,,,fee schedule,,,29296.81,,,percent of total billed charges,,,,,,,,,29296.81,,,percent of total billed charges,,,17956.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20873.98,,,percent of total billed charges,,,,,,,,,,,,,,,67.05,,,fee schedule,,,67.05,,,fee schedule,,,67.05,,,fee schedule,,,,,,,,,17285.12,,,percent of total billed charges,,,548.68,,,per diem,,,29296.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,29296.81,,,percent of total billed charges,,,24902.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15559.54,,,percent of total billed charges,,,29296.81,,,percent of total billed charges,,,29296.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19763.63,,,percent of total billed charges,,,23706.98,,,percent of total billed charges,,,,,,,,,,,,,,,11718.72,,,percent of total billed charges,,,,,,,,,171.62,,,fee schedule,,,123.49,,,fee schedule,,,,,,,,,29296.81,,,percent of total billed charges,,,,,,,,,,,,,,,2343.74,,,percent of total billed charges,,,29296.81,,,percent of total billed charges,,,,,,,,,,,,,,,29296.81,,,percent of total billed charges,,,29296.81,,,percent of total billed charges,,,,,,,,,73.34,,,fee schedule,,,,,,,,,,,,,,,63.57,,,fee schedule,,,84.76,,,fee schedule,,,47.67,,,fee schedule,,,68.83,,,fee schedule,,,29296.81,,,percent of total billed charges,,,29296.81,,,percent of total billed charges,,,29296.81,,,percent of total billed charges,,,,,,,,,20539.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14648.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17261.68,,,percent of total billed charges,,
PERTUZUMAB-TRASTMAB-HY-ZZXF 10,2500003808,CDM,636,RC,J9316,HCPCS,5024226001,NDC,9390,APC,,outpatient,facility,10,ML,29296.81,29296.81,61.32,10722.63,,,,,,,,65.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,63.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.52,,,fee schedule,,,,,,,,,10722.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,63.88,,,fee schedule,,,,,,,,,,,,,,,67.07,,,fee schedule,,,67.07,,,fee schedule,,,,,,,,,63.88,,,fee schedule,,,63.88,,,fee schedule,,,67.07,,,fee schedule,,,,,,,,,,,,,,,95.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,63.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.32,,,fee schedule,,,68.35,,,fee schedule,,,67.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.88,,,fee schedule,,,63.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,66.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,63.88,,,fee schedule,,,,,,,,,79.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,79.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,63.88,,,fee schedule,,,63.88,,,fee schedule,,,,,,,,,,,,,,,63.88,,,fee schedule,,,,,,,,,63.88,,,fee schedule,,,65.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.88,,,fee schedule,,,,,,,,,,,,,,,66.44,,,fee schedule,,,63.88,,,fee schedule,,,,,,,,,63.88,,,fee schedule,,,,,,,,,63.88,,,fee schedule,,,67.07,,,fee schedule,,,,,,,,
PERTUZUMAB-TRASTMAB-HY-ZZXF 10,2500003808,CDM,636,RC,J9316,HCPCS,5024226001,NDC,462,EAPG,,outpatient,facility,10,ML,29296.81,29296.81,4530.01,6840.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6840.32,,,fee schedule,,,4530.01,,,fee schedule,,,6081.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPINEPHRINE 5 MG NEB,2500003816,CDM,636,RC,J0171,HCPCS,5428810310,NDC,,,,inpatient,facility,5,ML,288.75,288.75,23.1,288.75,,,,,,,,,,,,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288.75,,,percent of total billed charges,,,,,,,,,288.75,,,percent of total billed charges,,,147.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.25,,,percent of total billed charges,,,,,,,,,,,,,,,288.75,,,percent of total billed charges,,,245.44,,,percent of total billed charges,,,,,,,,,,,,,,,288.75,,,percent of total billed charges,,,153.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,,23.1,,,percent of total billed charges,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.13,,,percent of total billed charges,,
EPINEPHRINE 5 MG NEB,2500003816,CDM,636,RC,J0171,HCPCS,5428810310,NDC,,,,outpatient,facility,5,ML,288.75,288.75,0.49,548.68,,204.75,,,percent of total billed charges,,,70.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,288.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,105.68,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.49,,,fee schedule,,,288.75,,,fee schedule,,,288.75,,,percent of total billed charges,,,,,,,,,288.75,,,percent of total billed charges,,,176.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,170.36,,,percent of total billed charges,,,548.68,,,per diem,,,288.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,288.75,,,percent of total billed charges,,,245.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,153.36,,,percent of total billed charges,,,288.75,,,percent of total billed charges,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.79,,,percent of total billed charges,,,233.66,,,percent of total billed charges,,,,,,,,,,,,,,,115.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,288.75,,,percent of total billed charges,,,288.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,288.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.1,,,percent of total billed charges,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,,288.75,,,percent of total billed charges,,,288.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.84,,,fee schedule,,,288.75,,,percent of total billed charges,,,288.75,,,percent of total billed charges,,,288.75,,,percent of total billed charges,,,,,,,,,202.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,170.13,,,percent of total billed charges,,
EPINEPHRINE 5 MG NEB,2500003816,CDM,636,RC,J0171,HCPCS,5428810310,NDC,496,EAPG,,outpatient,facility,5,ML,288.75,288.75,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INFLU (FLUCELVAX TRIV)PF 0.5ML,2500003847,CDM,636,RC,90661,CPT,7046165403,NDC,,,,inpatient,facility,0.5,UN,104.61,104.61,8.37,104.61,,,,,,,,,,,,,,104.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.61,,,percent of total billed charges,,,,,,,,,104.61,,,percent of total billed charges,,,53.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.77,,,percent of total billed charges,,,,,,,,,,,,,,,104.61,,,percent of total billed charges,,,88.92,,,percent of total billed charges,,,,,,,,,,,,,,,104.61,,,percent of total billed charges,,,55.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,104.61,,,percent of total billed charges,,,,,,,,,,,,,,,8.37,,,percent of total billed charges,,,104.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,104.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.64,,,percent of total billed charges,,
INFLU (FLUCELVAX TRIV)PF 0.5ML,2500003847,CDM,636,RC,90661,CPT,7046165403,NDC,,,,outpatient,facility,0.5,UN,104.61,104.61,8.37,548.68,,74.18,,,percent of total billed charges,,,20.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,104.61,,,percent of total billed charges,,,28.93,,,fee schedule,,,27.37,,,fee schedule,,,19.48,,,fee schedule,,,27.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,104.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.67,,,fee schedule,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,19.48,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,36.85,,,fee schedule,,,104.61,,,percent of total billed charges,,,19.48,,,fee schedule,,,104.61,,,percent of total billed charges,,,64.12,,,percent of total billed charges,,,20.45,,,fee schedule,,,20.45,,,fee schedule,,,,,,,,,19.88,,,fee schedule,,,19.48,,,fee schedule,,,20.45,,,fee schedule,,,74.53,,,percent of total billed charges,,,,,,,,,29.22,,,fee schedule,,,22.29,,,fee schedule,,,22.29,,,fee schedule,,,22.29,,,fee schedule,,,20.07,,,fee schedule,,,61.72,,,percent of total billed charges,,,548.68,,,per diem,,,104.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,104.61,,,percent of total billed charges,,,88.92,,,percent of total billed charges,,,18.8,,,fee schedule,,,20.84,,,fee schedule,,,20.87,,,fee schedule,,,55.56,,,percent of total billed charges,,,104.61,,,percent of total billed charges,,,104.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.48,,,fee schedule,,,19.48,,,fee schedule,,,70.57,,,percent of total billed charges,,,84.65,,,percent of total billed charges,,,,,,,,,20.68,,,fee schedule,,,41.84,,,percent of total billed charges,,,,,,,,,42.09,,,fee schedule,,,30.29,,,fee schedule,,,19.48,,,fee schedule,,,104.61,,,percent of total billed charges,,,24.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.37,,,percent of total billed charges,,,104.61,,,percent of total billed charges,,,19.48,,,fee schedule,,,29.22,,,fee schedule,,,104.61,,,percent of total billed charges,,,104.61,,,percent of total billed charges,,,19.48,,,fee schedule,,,17.99,,,fee schedule,,,19.48,,,fee schedule,,,20.06,,,fee schedule,,,15.59,,,fee schedule,,,20.79,,,fee schedule,,,11.69,,,fee schedule,,,23.13,,,fee schedule,,,104.61,,,percent of total billed charges,,,104.61,,,percent of total billed charges,,,104.61,,,percent of total billed charges,,,19.58,,,fee schedule,,,73.34,,,percent of total billed charges,,,19.48,,,fee schedule,,,20.77,,,fee schedule,,,19.48,,,fee schedule,,,19.48,,,fee schedule,,,19.88,,,fee schedule,,,52.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,19.88,,,fee schedule,,,20.45,,,fee schedule,,,61.64,,,percent of total billed charges,,
INFLU (FLUCELVAX TRIV)PF 0.5ML,2500003847,CDM,636,RC,90661,CPT,7046165403,NDC,414,EAPG,,outpatient,facility,0.5,UN,104.61,104.61,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DACARBAZINE INJ 100MG,2500003900,CDM,636,RC,J9130,HCPCS,6332312710,NDC,,,,inpatient,facility,10,GR,40.88,40.88,3.27,40.88,,,,,,,,,,,,,,40.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.88,,,percent of total billed charges,,,,,,,,,40.88,,,percent of total billed charges,,,20.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.53,,,percent of total billed charges,,,,,,,,,,,,,,,40.88,,,percent of total billed charges,,,34.75,,,percent of total billed charges,,,,,,,,,,,,,,,40.88,,,percent of total billed charges,,,21.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,40.88,,,percent of total billed charges,,,,,,,,,,,,,,,3.27,,,percent of total billed charges,,,40.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.09,,,percent of total billed charges,,
DACARBAZINE INJ 100MG,2500003900,CDM,636,RC,J9130,HCPCS,6332312710,NDC,,,,outpatient,facility,10,GR,40.88,40.88,3.27,548.68,,3.69,,,fee schedule,,,9.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,40.88,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,40.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,14.96,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.35,,,fee schedule,,,40.88,,,fee schedule,,,40.88,,,percent of total billed charges,,,,,,,,,40.88,,,percent of total billed charges,,,25.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,24.12,,,percent of total billed charges,,,548.68,,,per diem,,,40.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,40.88,,,percent of total billed charges,,,34.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.71,,,percent of total billed charges,,,40.88,,,percent of total billed charges,,,40.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.58,,,percent of total billed charges,,,33.08,,,percent of total billed charges,,,,,,,,,,,,,,,16.35,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,40.88,,,percent of total billed charges,,,40.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.27,,,percent of total billed charges,,,40.88,,,percent of total billed charges,,,,,,,,,,,,,,,40.88,,,percent of total billed charges,,,40.88,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.73,,,fee schedule,,,40.88,,,percent of total billed charges,,,40.88,,,percent of total billed charges,,,40.88,,,percent of total billed charges,,,,,,,,,28.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,24.09,,,percent of total billed charges,,
DACARBAZINE INJ 100MG,2500003900,CDM,636,RC,J9130,HCPCS,6332312710,NDC,430,EAPG,,outpatient,facility,10,GR,40.88,40.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DACARBAZINE INJ 200MG,2500003910,CDM,636,RC,J9130,HCPCS,143924510,NDC,,,,inpatient,facility,20,GR,39.6,39.6,3.17,39.6,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,,,,,,,39.6,,,percent of total billed charges,,,20.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,21.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.33,,,percent of total billed charges,,
DACARBAZINE INJ 200MG,2500003910,CDM,636,RC,J9130,HCPCS,143924510,NDC,,,,outpatient,facility,20,GR,39.6,39.6,3.17,548.68,,3.69,,,fee schedule,,,9.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,39.6,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,14.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.35,,,fee schedule,,,39.6,,,fee schedule,,,39.6,,,percent of total billed charges,,,,,,,,,39.6,,,percent of total billed charges,,,24.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,23.36,,,percent of total billed charges,,,548.68,,,per diem,,,39.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,39.6,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.03,,,percent of total billed charges,,,39.6,,,percent of total billed charges,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.71,,,percent of total billed charges,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,15.84,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,39.6,,,percent of total billed charges,,,39.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,39.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.17,,,percent of total billed charges,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.73,,,fee schedule,,,39.6,,,percent of total billed charges,,,39.6,,,percent of total billed charges,,,39.6,,,percent of total billed charges,,,,,,,,,27.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,23.33,,,percent of total billed charges,,
DACARBAZINE INJ 200MG,2500003910,CDM,636,RC,J9130,HCPCS,143924510,NDC,430,EAPG,,outpatient,facility,20,GR,39.6,39.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOCETAXEL INJ 20 MG,2500003930,CDM,636,RC,J9171,HCPCS,6745753102,NDC,,,,inpatient,facility,2,GR,272.25,272.25,21.78,272.25,,,,,,,,,,,,,,272.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.25,,,percent of total billed charges,,,,,,,,,272.25,,,percent of total billed charges,,,139.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.35,,,percent of total billed charges,,,,,,,,,,,,,,,272.25,,,percent of total billed charges,,,231.41,,,percent of total billed charges,,,,,,,,,,,,,,,272.25,,,percent of total billed charges,,,144.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,272.25,,,percent of total billed charges,,,,,,,,,,,,,,,21.78,,,percent of total billed charges,,,272.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,272.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.41,,,percent of total billed charges,,
DOCETAXEL INJ 20 MG,2500003930,CDM,636,RC,J9171,HCPCS,6745753102,NDC,,,,outpatient,facility,2,GR,272.25,272.25,0.9,548.68,,193.05,,,percent of total billed charges,,,66.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,272.25,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,272.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,99.64,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,22.37,,,fee schedule,,,272.25,,,fee schedule,,,272.25,,,percent of total billed charges,,,,,,,,,272.25,,,percent of total billed charges,,,166.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.98,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,fee schedule,,,1,,,fee schedule,,,1,,,fee schedule,,,,,,,,,160.63,,,percent of total billed charges,,,548.68,,,per diem,,,272.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,272.25,,,percent of total billed charges,,,231.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,144.59,,,percent of total billed charges,,,272.25,,,percent of total billed charges,,,272.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.66,,,percent of total billed charges,,,220.3,,,percent of total billed charges,,,,,,,,,,,,,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,272.25,,,percent of total billed charges,,,272.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,272.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.78,,,percent of total billed charges,,,272.25,,,percent of total billed charges,,,,,,,,,,,,,,,272.25,,,percent of total billed charges,,,272.25,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.9,,,fee schedule,,,272.25,,,percent of total billed charges,,,272.25,,,percent of total billed charges,,,272.25,,,percent of total billed charges,,,,,,,,,190.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,160.41,,,percent of total billed charges,,
DOCETAXEL INJ 20 MG,2500003930,CDM,636,RC,J9171,HCPCS,6745753102,NDC,431,EAPG,,outpatient,facility,2,GR,272.25,272.25,42.81,64.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.64,,,fee schedule,,,42.81,,,fee schedule,,,57.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.81,,,fee schedule,,,42.81,,,fee schedule,,,42.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,42.81,,,fee schedule,,,,,,,,,,,,,,,42.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOCETAXEL INJ 80 MG,2500003932,CDM,636,RC,J9171,HCPCS,6745753208,NDC,,,,inpatient,facility,8,GR,1089,1089,87.12,1089,,,,,,,,,,,,,,1089,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1089,,,percent of total billed charges,,,,,,,,,1089,,,percent of total billed charges,,,556.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,653.4,,,percent of total billed charges,,,,,,,,,,,,,,,1089,,,percent of total billed charges,,,925.65,,,percent of total billed charges,,,,,,,,,,,,,,,1089,,,percent of total billed charges,,,578.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,435.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1089,,,percent of total billed charges,,,,,,,,,,,,,,,87.12,,,percent of total billed charges,,,1089,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1089,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.64,,,percent of total billed charges,,
DOCETAXEL INJ 80 MG,2500003932,CDM,636,RC,J9171,HCPCS,6745753208,NDC,,,,outpatient,facility,8,GR,1089,1089,0.9,1089,,772.21,,,percent of total billed charges,,,265.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1089,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,1089,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,398.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,22.37,,,fee schedule,,,1089,,,fee schedule,,,1089,,,percent of total billed charges,,,,,,,,,1089,,,percent of total billed charges,,,667.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,775.91,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,fee schedule,,,1,,,fee schedule,,,1,,,fee schedule,,,,,,,,,642.51,,,percent of total billed charges,,,548.68,,,per diem,,,1089,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1089,,,percent of total billed charges,,,925.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,578.37,,,percent of total billed charges,,,1089,,,percent of total billed charges,,,1089,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,734.64,,,percent of total billed charges,,,881.22,,,percent of total billed charges,,,,,,,,,,,,,,,435.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1089,,,percent of total billed charges,,,1089,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1089,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,87.12,,,percent of total billed charges,,,1089,,,percent of total billed charges,,,,,,,,,,,,,,,1089,,,percent of total billed charges,,,1089,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.9,,,fee schedule,,,1089,,,percent of total billed charges,,,1089,,,percent of total billed charges,,,1089,,,percent of total billed charges,,,,,,,,,763.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,544.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,641.64,,,percent of total billed charges,,
DOCETAXEL INJ 80 MG,2500003932,CDM,636,RC,J9171,HCPCS,6745753208,NDC,431,EAPG,,outpatient,facility,8,GR,1089,1089,42.81,64.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.64,,,fee schedule,,,42.81,,,fee schedule,,,57.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.81,,,fee schedule,,,42.81,,,fee schedule,,,42.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,42.81,,,fee schedule,,,,,,,,,,,,,,,42.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ETOPOSIDE INJ 100 MG,2500003950,CDM,636,RC,J9181,HCPCS,6126941020,NDC,,,,inpatient,facility,100,UN,562.15,562.15,44.97,562.15,,,,,,,,,,,,,,562.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.15,,,percent of total billed charges,,,,,,,,,562.15,,,percent of total billed charges,,,287.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,478.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.29,,,percent of total billed charges,,,,,,,,,,,,,,,562.15,,,percent of total billed charges,,,477.83,,,percent of total billed charges,,,,,,,,,,,,,,,562.15,,,percent of total billed charges,,,298.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,562.15,,,percent of total billed charges,,,,,,,,,,,,,,,44.97,,,percent of total billed charges,,,562.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,562.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.22,,,percent of total billed charges,,
ETOPOSIDE INJ 100 MG,2500003950,CDM,636,RC,J9181,HCPCS,6126941020,NDC,,,,outpatient,facility,100,UN,562.15,562.15,1,562.15,,1.05,,,fee schedule,,,137.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,562.15,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,562.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,205.75,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1,,,fee schedule,,,562.15,,,fee schedule,,,562.15,,,percent of total billed charges,,,,,,,,,562.15,,,percent of total billed charges,,,344.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,331.67,,,percent of total billed charges,,,548.68,,,per diem,,,562.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,562.15,,,percent of total billed charges,,,477.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,298.56,,,percent of total billed charges,,,562.15,,,percent of total billed charges,,,562.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,379.23,,,percent of total billed charges,,,454.89,,,percent of total billed charges,,,,,,,,,,,,,,,224.86,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,562.15,,,percent of total billed charges,,,562.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,562.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,44.97,,,percent of total billed charges,,,562.15,,,percent of total billed charges,,,,,,,,,,,,,,,562.15,,,percent of total billed charges,,,562.15,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.18,,,fee schedule,,,562.15,,,percent of total billed charges,,,562.15,,,percent of total billed charges,,,562.15,,,percent of total billed charges,,,,,,,,,394.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,331.22,,,percent of total billed charges,,
ETOPOSIDE INJ 100 MG,2500003950,CDM,636,RC,J9181,HCPCS,6126941020,NDC,495,EAPG,,outpatient,facility,100,UN,562.15,562.15,21.18,31.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.98,,,fee schedule,,,21.18,,,fee schedule,,,28.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,21.18,,,fee schedule,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUOROURACIL INJ 500 MG,2500003970,CDM,636,RC,J9190,HCPCS,1672927668,NDC,,,,inpatient,facility,10,UN,52.6,52.6,4.21,52.6,,,,,,,,,,,,,,52.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.6,,,percent of total billed charges,,,,,,,,,52.6,,,percent of total billed charges,,,26.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.56,,,percent of total billed charges,,,,,,,,,,,,,,,52.6,,,percent of total billed charges,,,44.71,,,percent of total billed charges,,,,,,,,,,,,,,,52.6,,,percent of total billed charges,,,27.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,52.6,,,percent of total billed charges,,,,,,,,,,,,,,,4.21,,,percent of total billed charges,,,52.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.99,,,percent of total billed charges,,
FLUOROURACIL INJ 500 MG,2500003970,CDM,636,RC,J9190,HCPCS,1672927668,NDC,,,,outpatient,facility,10,UN,52.6,52.6,1.66,548.68,,2.95,,,fee schedule,,,12.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,52.6,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,52.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,19.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.66,,,fee schedule,,,52.6,,,fee schedule,,,52.6,,,percent of total billed charges,,,,,,,,,52.6,,,percent of total billed charges,,,32.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,31.03,,,percent of total billed charges,,,548.68,,,per diem,,,52.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,52.6,,,percent of total billed charges,,,44.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.94,,,percent of total billed charges,,,52.6,,,percent of total billed charges,,,52.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.48,,,percent of total billed charges,,,42.56,,,percent of total billed charges,,,,,,,,,,,,,,,21.04,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,52.6,,,percent of total billed charges,,,52.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,52.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.21,,,percent of total billed charges,,,52.6,,,percent of total billed charges,,,,,,,,,,,,,,,52.6,,,percent of total billed charges,,,52.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.34,,,fee schedule,,,52.6,,,percent of total billed charges,,,52.6,,,percent of total billed charges,,,52.6,,,percent of total billed charges,,,,,,,,,36.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,30.99,,,percent of total billed charges,,
FLUOROURACIL INJ 500 MG,2500003970,CDM,636,RC,J9190,HCPCS,1672927668,NDC,495,EAPG,,outpatient,facility,10,UN,52.6,52.6,21.18,31.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.98,,,fee schedule,,,21.18,,,fee schedule,,,28.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,21.18,,,fee schedule,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GEMCITABINE INJ 200 MG,2500003990,CDM,636,RC,J9201,HCPCS,409018301,NDC,,,,inpatient,facility,5.26,UN,30.78,30.78,2.46,30.78,,,,,,,,,,,,,,30.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.78,,,percent of total billed charges,,,,,,,,,30.78,,,percent of total billed charges,,,15.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.47,,,percent of total billed charges,,,,,,,,,,,,,,,30.78,,,percent of total billed charges,,,26.16,,,percent of total billed charges,,,,,,,,,,,,,,,30.78,,,percent of total billed charges,,,16.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,30.78,,,percent of total billed charges,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,30.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.14,,,percent of total billed charges,,
GEMCITABINE INJ 200 MG,2500003990,CDM,636,RC,J9201,HCPCS,409018301,NDC,,,,outpatient,facility,5.26,UN,30.78,30.78,2.46,548.68,,3.65,,,fee schedule,,,7.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,30.78,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,30.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.27,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,30.78,,,fee schedule,,,30.78,,,fee schedule,,,30.78,,,percent of total billed charges,,,,,,,,,30.78,,,percent of total billed charges,,,18.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,18.16,,,percent of total billed charges,,,548.68,,,per diem,,,30.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,30.78,,,percent of total billed charges,,,26.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.35,,,percent of total billed charges,,,30.78,,,percent of total billed charges,,,30.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.76,,,percent of total billed charges,,,24.91,,,percent of total billed charges,,,,,,,,,,,,,,,12.31,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,30.78,,,percent of total billed charges,,,30.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.46,,,percent of total billed charges,,,30.78,,,percent of total billed charges,,,,,,,,,,,,,,,30.78,,,percent of total billed charges,,,30.78,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.42,,,fee schedule,,,30.78,,,percent of total billed charges,,,30.78,,,percent of total billed charges,,,30.78,,,percent of total billed charges,,,,,,,,,21.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.14,,,percent of total billed charges,,
GEMCITABINE INJ 200 MG,2500003990,CDM,636,RC,J9201,HCPCS,409018301,NDC,435,EAPG,,outpatient,facility,5.26,UN,30.78,30.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GEMCITABINE INJ 1 GM,2500003992,CDM,636,RC,J9201,HCPCS,7086020550,NDC,,,,inpatient,facility,1000,UN,155.1,155.1,12.41,155.1,,,,,,,,,,,,,,155.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.1,,,percent of total billed charges,,,,,,,,,155.1,,,percent of total billed charges,,,79.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.06,,,percent of total billed charges,,,,,,,,,,,,,,,155.1,,,percent of total billed charges,,,131.83,,,percent of total billed charges,,,,,,,,,,,,,,,155.1,,,percent of total billed charges,,,82.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,155.1,,,percent of total billed charges,,,,,,,,,,,,,,,12.41,,,percent of total billed charges,,,155.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,155.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.38,,,percent of total billed charges,,
GEMCITABINE INJ 1 GM,2500003992,CDM,636,RC,J9201,HCPCS,7086020550,NDC,,,,outpatient,facility,1000,UN,155.1,155.1,3.42,548.68,,3.65,,,fee schedule,,,37.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,155.1,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,155.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,56.77,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,109.36,,,fee schedule,,,155.1,,,fee schedule,,,155.1,,,percent of total billed charges,,,,,,,,,155.1,,,percent of total billed charges,,,95.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,91.51,,,percent of total billed charges,,,548.68,,,per diem,,,155.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,155.1,,,percent of total billed charges,,,131.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.37,,,percent of total billed charges,,,155.1,,,percent of total billed charges,,,155.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.63,,,percent of total billed charges,,,125.51,,,percent of total billed charges,,,,,,,,,,,,,,,62.04,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,155.1,,,percent of total billed charges,,,155.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,155.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.41,,,percent of total billed charges,,,155.1,,,percent of total billed charges,,,,,,,,,,,,,,,155.1,,,percent of total billed charges,,,155.1,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.42,,,fee schedule,,,155.1,,,percent of total billed charges,,,155.1,,,percent of total billed charges,,,155.1,,,percent of total billed charges,,,,,,,,,108.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,91.38,,,percent of total billed charges,,
GEMCITABINE INJ 1 GM,2500003992,CDM,636,RC,J9201,HCPCS,7086020550,NDC,435,EAPG,,outpatient,facility,1000,UN,155.1,155.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GEMCITABINE INJ 2 GM,2500003993,CDM,636,RC,J9201,HCPCS,409018201,NDC,,,,inpatient,facility,52.6,UN,298.98,298.98,23.92,298.98,,,,,,,,,,,,,,298.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.98,,,percent of total billed charges,,,,,,,,,298.98,,,percent of total billed charges,,,152.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.39,,,percent of total billed charges,,,,,,,,,,,,,,,298.98,,,percent of total billed charges,,,254.13,,,percent of total billed charges,,,,,,,,,,,,,,,298.98,,,percent of total billed charges,,,158.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,298.98,,,percent of total billed charges,,,,,,,,,,,,,,,23.92,,,percent of total billed charges,,,298.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,298.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.16,,,percent of total billed charges,,
GEMCITABINE INJ 2 GM,2500003993,CDM,636,RC,J9201,HCPCS,409018201,NDC,,,,outpatient,facility,52.6,UN,298.98,298.98,3.42,548.68,,3.65,,,fee schedule,,,72.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,298.98,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,298.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,109.43,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,109.36,,,fee schedule,,,298.98,,,fee schedule,,,298.98,,,percent of total billed charges,,,,,,,,,298.98,,,percent of total billed charges,,,183.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,176.4,,,percent of total billed charges,,,548.68,,,per diem,,,298.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,298.98,,,percent of total billed charges,,,254.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,158.79,,,percent of total billed charges,,,298.98,,,percent of total billed charges,,,298.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.69,,,percent of total billed charges,,,241.93,,,percent of total billed charges,,,,,,,,,,,,,,,119.59,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,298.98,,,percent of total billed charges,,,298.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,298.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.92,,,percent of total billed charges,,,298.98,,,percent of total billed charges,,,,,,,,,,,,,,,298.98,,,percent of total billed charges,,,298.98,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.42,,,fee schedule,,,298.98,,,percent of total billed charges,,,298.98,,,percent of total billed charges,,,298.98,,,percent of total billed charges,,,,,,,,,209.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,176.16,,,percent of total billed charges,,
GEMCITABINE INJ 2 GM,2500003993,CDM,636,RC,J9201,HCPCS,409018201,NDC,435,EAPG,,outpatient,facility,52.6,UN,298.98,298.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IRINOTECAN INJ 100MG,2500004012,CDM,636,RC,J9206,HCPCS,6050561281,NDC,,,,inpatient,facility,5,GR,119.03,119.03,9.52,119.03,,,,,,,,,,,,,,119.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.03,,,percent of total billed charges,,,,,,,,,119.03,,,percent of total billed charges,,,60.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.42,,,percent of total billed charges,,,,,,,,,,,,,,,119.03,,,percent of total billed charges,,,101.18,,,percent of total billed charges,,,,,,,,,,,,,,,119.03,,,percent of total billed charges,,,63.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,119.03,,,percent of total billed charges,,,,,,,,,,,,,,,9.52,,,percent of total billed charges,,,119.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.13,,,percent of total billed charges,,
IRINOTECAN INJ 100MG,2500004012,CDM,636,RC,J9206,HCPCS,6050561281,NDC,,,,outpatient,facility,5,GR,119.03,119.03,2.82,548.68,,3.51,,,fee schedule,,,29.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,119.03,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,119.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,43.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.95,,,fee schedule,,,119.03,,,fee schedule,,,119.03,,,percent of total billed charges,,,,,,,,,119.03,,,percent of total billed charges,,,72.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,70.23,,,percent of total billed charges,,,548.68,,,per diem,,,119.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,119.03,,,percent of total billed charges,,,101.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.22,,,percent of total billed charges,,,119.03,,,percent of total billed charges,,,119.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.3,,,percent of total billed charges,,,96.32,,,percent of total billed charges,,,,,,,,,,,,,,,47.61,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,119.03,,,percent of total billed charges,,,119.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,119.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.52,,,percent of total billed charges,,,119.03,,,percent of total billed charges,,,,,,,,,,,,,,,119.03,,,percent of total billed charges,,,119.03,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.82,,,fee schedule,,,119.03,,,percent of total billed charges,,,119.03,,,percent of total billed charges,,,119.03,,,percent of total billed charges,,,,,,,,,83.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,70.13,,,percent of total billed charges,,
IRINOTECAN INJ 100MG,2500004012,CDM,636,RC,J9206,HCPCS,6050561281,NDC,430,EAPG,,outpatient,facility,5,GR,119.03,119.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IRINOTECAN INJ 40 MG,2500004015,CDM,636,RC,J9206,HCPCS,6050561280,NDC,,,,inpatient,facility,2,GR,57.58,57.58,4.61,57.58,,,,,,,,,,,,,,57.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.58,,,percent of total billed charges,,,,,,,,,57.58,,,percent of total billed charges,,,29.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.55,,,percent of total billed charges,,,,,,,,,,,,,,,57.58,,,percent of total billed charges,,,48.94,,,percent of total billed charges,,,,,,,,,,,,,,,57.58,,,percent of total billed charges,,,30.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,57.58,,,percent of total billed charges,,,,,,,,,,,,,,,4.61,,,percent of total billed charges,,,57.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.93,,,percent of total billed charges,,
IRINOTECAN INJ 40 MG,2500004015,CDM,636,RC,J9206,HCPCS,6050561280,NDC,,,,outpatient,facility,2,GR,57.58,57.58,2.82,548.68,,3.51,,,fee schedule,,,14.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,57.58,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,57.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,21.07,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.95,,,fee schedule,,,57.58,,,fee schedule,,,57.58,,,percent of total billed charges,,,,,,,,,57.58,,,percent of total billed charges,,,35.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,33.97,,,percent of total billed charges,,,548.68,,,per diem,,,57.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,57.58,,,percent of total billed charges,,,48.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.58,,,percent of total billed charges,,,57.58,,,percent of total billed charges,,,57.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.84,,,percent of total billed charges,,,46.59,,,percent of total billed charges,,,,,,,,,,,,,,,23.03,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,57.58,,,percent of total billed charges,,,57.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,57.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.61,,,percent of total billed charges,,,57.58,,,percent of total billed charges,,,,,,,,,,,,,,,57.58,,,percent of total billed charges,,,57.58,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.82,,,fee schedule,,,57.58,,,percent of total billed charges,,,57.58,,,percent of total billed charges,,,57.58,,,percent of total billed charges,,,,,,,,,40.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.79,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,33.93,,,percent of total billed charges,,
IRINOTECAN INJ 40 MG,2500004015,CDM,636,RC,J9206,HCPCS,6050561280,NDC,430,EAPG,,outpatient,facility,2,GR,57.58,57.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESNA INJ 1 GM,2500004032,CDM,636,RC,J9209,HCPCS,2502120111,NDC,,,,inpatient,facility,10,UN,66,66,5.28,66,,,,,,,,,,,,,,66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66,,,percent of total billed charges,,,,,,,,,66,,,percent of total billed charges,,,33.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,66,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,66,,,percent of total billed charges,,,35.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,66,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.89,,,percent of total billed charges,,
MESNA INJ 1 GM,2500004032,CDM,636,RC,J9209,HCPCS,2502120111,NDC,,,,outpatient,facility,10,UN,66,66,1.76,548.68,,1.76,,,fee schedule,,,16.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,66,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,24.16,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,66,,,fee schedule,,,66,,,percent of total billed charges,,,,,,,,,66,,,percent of total billed charges,,,40.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,38.94,,,percent of total billed charges,,,548.68,,,per diem,,,66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,66,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.05,,,percent of total billed charges,,,66,,,percent of total billed charges,,,66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.52,,,percent of total billed charges,,,53.41,,,percent of total billed charges,,,,,,,,,,,,,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,66,,,percent of total billed charges,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.28,,,percent of total billed charges,,,66,,,percent of total billed charges,,,,,,,,,,,,,,,66,,,percent of total billed charges,,,66,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.85,,,fee schedule,,,66,,,percent of total billed charges,,,66,,,percent of total billed charges,,,66,,,percent of total billed charges,,,,,,,,,46.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,38.89,,,percent of total billed charges,,
MESNA INJ 1 GM,2500004032,CDM,636,RC,J9209,HCPCS,2502120111,NDC,430,EAPG,,outpatient,facility,10,UN,66,66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEUPROLIDE ACET DEPOT 7.5 MG,2500004090,CDM,636,RC,J9217,HCPCS,6293575375,NDC,,,,inpatient,facility,7.5,UN,1490.58,1490.58,119.25,1490.58,,,,,,,,,,,,,,1490.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1490.58,,,percent of total billed charges,,,,,,,,,1490.58,,,percent of total billed charges,,,761.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1269.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.35,,,percent of total billed charges,,,,,,,,,,,,,,,1490.58,,,percent of total billed charges,,,1266.99,,,percent of total billed charges,,,,,,,,,,,,,,,1490.58,,,percent of total billed charges,,,791.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,596.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1490.58,,,percent of total billed charges,,,,,,,,,,,,,,,119.25,,,percent of total billed charges,,,1490.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1490.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.25,,,percent of total billed charges,,
LEUPROLIDE ACET DEPOT 7.5 MG,2500004090,CDM,636,RC,J9217,HCPCS,6293575375,NDC,,,,outpatient,facility,7.5,UN,1490.58,1490.58,113.61,1490.58,,185.66,,,fee schedule,,,,,,,,,1490.58,,,percent of total billed charges,,,234.34,,,fee schedule,,,221.7,,,fee schedule,,,,,,,,,221.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1490.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,230.11,,,fee schedule,,,1490.58,,,fee schedule,,,1490.58,,,percent of total billed charges,,,,,,,,,1490.58,,,percent of total billed charges,,,913.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1062.04,,,percent of total billed charges,,,,,,,,,,,,,,,181.3,,,fee schedule,,,181.3,,,fee schedule,,,181.3,,,fee schedule,,,,,,,,,879.44,,,percent of total billed charges,,,548.68,,,per diem,,,1490.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1490.58,,,percent of total billed charges,,,1266.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,791.65,,,percent of total billed charges,,,1490.58,,,percent of total billed charges,,,1490.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1005.55,,,percent of total billed charges,,,1206.18,,,percent of total billed charges,,,,,,,,,,,,,,,596.23,,,percent of total billed charges,,,,,,,,,409.02,,,fee schedule,,,294.32,,,fee schedule,,,,,,,,,1490.58,,,percent of total billed charges,,,,,,,,,,,,,,,119.25,,,percent of total billed charges,,,1490.58,,,percent of total billed charges,,,,,,,,,,,,,,,1490.58,,,percent of total billed charges,,,1490.58,,,percent of total billed charges,,,,,,,,,174.79,,,fee schedule,,,,,,,,,,,,,,,151.49,,,fee schedule,,,201.99,,,fee schedule,,,113.61,,,fee schedule,,,187.35,,,fee schedule,,,1490.58,,,percent of total billed charges,,,1490.58,,,percent of total billed charges,,,1490.58,,,percent of total billed charges,,,,,,,,,1045.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,745.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,878.25,,,percent of total billed charges,,
LEUPROLIDE ACET DEPOT 7.5 MG,2500004090,CDM,636,RC,J9217,HCPCS,6293575375,NDC,9217,APC,,outpatient,facility,7.5,UN,1490.58,1490.58,173.56,545.55,,,,,,,,186.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.6,,,fee schedule,,,,,,,,,545.55,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,189.83,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,180.79,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,,,,,,,,271.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.56,,,fee schedule,,,193.45,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,180.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,188.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,225.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,225.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,180.79,,,fee schedule,,,180.79,,,fee schedule,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,186.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,188.02,,,fee schedule,,,180.79,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,
LEUPROLIDE ACET DEPOT 7.5 MG,2500004090,CDM,636,RC,J9217,HCPCS,6293575375,NDC,434,EAPG,,outpatient,facility,7.5,UN,1490.58,1490.58,380.24,574.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,574.16,,,fee schedule,,,380.24,,,fee schedule,,,510.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,380.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,380.24,,,fee schedule,,,380.24,,,fee schedule,,,380.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,380.24,,,fee schedule,,,,,,,,,,,,,,,380.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHOTREXATE INJ 50 MG  (2ML),2500004140,CDM,636,RC,J9260,HCPCS,6170335038,NDC,,,,inpatient,facility,2,UN,23.99,23.99,1.92,23.99,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,,,,,,,23.99,,,percent of total billed charges,,,12.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.39,,,percent of total billed charges,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,20.39,,,percent of total billed charges,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.13,,,percent of total billed charges,,
METHOTREXATE INJ 50 MG  (2ML),2500004140,CDM,636,RC,J9260,HCPCS,6170335038,NDC,,,,outpatient,facility,2,UN,23.99,23.99,1.92,548.68,,2.57,,,fee schedule,,,5.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,23.99,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.78,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.13,,,fee schedule,,,23.99,,,fee schedule,,,23.99,,,percent of total billed charges,,,,,,,,,23.99,,,percent of total billed charges,,,14.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,14.15,,,percent of total billed charges,,,548.68,,,per diem,,,23.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,23.99,,,percent of total billed charges,,,20.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.18,,,percent of total billed charges,,,19.41,,,percent of total billed charges,,,,,,,,,,,,,,,9.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,23.99,,,percent of total billed charges,,,23.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.92,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,,23.99,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.67,,,fee schedule,,,23.99,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,23.99,,,percent of total billed charges,,,,,,,,,16.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.13,,,percent of total billed charges,,
METHOTREXATE INJ 50 MG  (2ML),2500004140,CDM,636,RC,J9260,HCPCS,6170335038,NDC,495,EAPG,,outpatient,facility,2,UN,23.99,23.99,21.18,31.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.98,,,fee schedule,,,21.18,,,fee schedule,,,28.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,21.18,,,fee schedule,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MITOMYCIN INJ 5 MG,2500004190,CDM,636,RC,J9280,HCPCS,1672911505,NDC,,,,inpatient,facility,5,GR,899.12,899.12,71.93,899.12,,,,,,,,,,,,,,899.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,899.12,,,percent of total billed charges,,,,,,,,,899.12,,,percent of total billed charges,,,459.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,765.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,539.47,,,percent of total billed charges,,,,,,,,,,,,,,,899.12,,,percent of total billed charges,,,764.25,,,percent of total billed charges,,,,,,,,,,,,,,,899.12,,,percent of total billed charges,,,477.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,899.12,,,percent of total billed charges,,,,,,,,,,,,,,,71.93,,,percent of total billed charges,,,899.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,899.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,529.76,,,percent of total billed charges,,
MITOMYCIN INJ 5 MG,2500004190,CDM,636,RC,J9280,HCPCS,1672911505,NDC,,,,outpatient,facility,5,GR,899.12,899.12,37.05,899.12,,67.03,,,fee schedule,,,,,,,,,899.12,,,percent of total billed charges,,,70.3,,,fee schedule,,,66.51,,,fee schedule,,,,,,,,,66.51,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,899.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,899.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,899.12,,,fee schedule,,,899.12,,,percent of total billed charges,,,,,,,,,899.12,,,percent of total billed charges,,,551.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,640.62,,,percent of total billed charges,,,,,,,,,,,,,,,63.35,,,fee schedule,,,63.35,,,fee schedule,,,63.35,,,fee schedule,,,,,,,,,530.48,,,percent of total billed charges,,,548.68,,,per diem,,,899.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,899.12,,,percent of total billed charges,,,764.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,477.52,,,percent of total billed charges,,,899.12,,,percent of total billed charges,,,899.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,606.55,,,percent of total billed charges,,,727.57,,,percent of total billed charges,,,,,,,,,,,,,,,359.65,,,percent of total billed charges,,,,,,,,,133.39,,,fee schedule,,,95.98,,,fee schedule,,,,,,,,,899.12,,,percent of total billed charges,,,,,,,,,,,,,,,71.93,,,percent of total billed charges,,,899.12,,,percent of total billed charges,,,,,,,,,,,,,,,899.12,,,percent of total billed charges,,,899.12,,,percent of total billed charges,,,,,,,,,57,,,fee schedule,,,,,,,,,,,,,,,49.41,,,fee schedule,,,65.88,,,fee schedule,,,37.05,,,fee schedule,,,56.21,,,fee schedule,,,899.12,,,percent of total billed charges,,,899.12,,,percent of total billed charges,,,899.12,,,percent of total billed charges,,,,,,,,,630.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,449.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,529.76,,,percent of total billed charges,,
MITOMYCIN INJ 5 MG,2500004190,CDM,636,RC,J9280,HCPCS,1672911505,NDC,1232,APC,,outpatient,facility,5,GR,899.12,899.12,44.5,329.08,,,,,,,,47.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,46.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.81,,,fee schedule,,,,,,,,,329.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,46.35,,,fee schedule,,,,,,,,,,,,,,,48.67,,,fee schedule,,,48.67,,,fee schedule,,,,,,,,,46.35,,,fee schedule,,,46.35,,,fee schedule,,,48.67,,,fee schedule,,,,,,,,,,,,,,,69.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.5,,,fee schedule,,,49.59,,,fee schedule,,,48.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.35,,,fee schedule,,,46.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,48.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,46.35,,,fee schedule,,,,,,,,,57.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,57.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,46.35,,,fee schedule,,,46.35,,,fee schedule,,,,,,,,,,,,,,,46.35,,,fee schedule,,,,,,,,,46.35,,,fee schedule,,,47.74,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.35,,,fee schedule,,,,,,,,,,,,,,,48.2,,,fee schedule,,,46.35,,,fee schedule,,,,,,,,,46.35,,,fee schedule,,,,,,,,,46.35,,,fee schedule,,,48.67,,,fee schedule,,,,,,,,
MITOMYCIN INJ 5 MG,2500004190,CDM,636,RC,J9280,HCPCS,1672911505,NDC,433,EAPG,,outpatient,facility,5,GR,899.12,899.12,349.48,527.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,527.71,,,fee schedule,,,349.48,,,fee schedule,,,469.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.48,,,fee schedule,,,349.48,,,fee schedule,,,349.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,349.48,,,fee schedule,,,,,,,,,,,,,,,349.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VINBLASTINE SULF INJ 1 MG,2500004250,CDM,636,RC,J9360,HCPCS,6332327810,NDC,,,,inpatient,facility,1,UN,17.75,17.75,1.42,17.75,,,,,,,,,,,,,,17.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.75,,,percent of total billed charges,,,,,,,,,17.75,,,percent of total billed charges,,,9.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.65,,,percent of total billed charges,,,,,,,,,,,,,,,17.75,,,percent of total billed charges,,,15.09,,,percent of total billed charges,,,,,,,,,,,,,,,17.75,,,percent of total billed charges,,,9.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,17.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,17.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.46,,,percent of total billed charges,,
VINBLASTINE SULF INJ 1 MG,2500004250,CDM,636,RC,J9360,HCPCS,6332327810,NDC,,,,outpatient,facility,1,UN,17.75,17.75,1.2,548.68,,5.02,,,fee schedule,,,4.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,17.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,17.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.5,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.2,,,fee schedule,,,17.75,,,fee schedule,,,17.75,,,percent of total billed charges,,,,,,,,,17.75,,,percent of total billed charges,,,10.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,10.47,,,percent of total billed charges,,,548.68,,,per diem,,,17.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,17.75,,,percent of total billed charges,,,15.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.43,,,percent of total billed charges,,,17.75,,,percent of total billed charges,,,17.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.97,,,percent of total billed charges,,,14.36,,,percent of total billed charges,,,,,,,,,,,,,,,7.1,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17.75,,,percent of total billed charges,,,17.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.42,,,percent of total billed charges,,,17.75,,,percent of total billed charges,,,,,,,,,,,,,,,17.75,,,percent of total billed charges,,,17.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,4.03,,,fee schedule,,,17.75,,,percent of total billed charges,,,17.75,,,percent of total billed charges,,,17.75,,,percent of total billed charges,,,,,,,,,12.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.46,,,percent of total billed charges,,
VINBLASTINE SULF INJ 1 MG,2500004250,CDM,636,RC,J9360,HCPCS,6332327810,NDC,430,EAPG,,outpatient,facility,1,UN,17.75,17.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VINCRISTINE SULF INJ 1 MG,2500004260,CDM,636,RC,J9370,HCPCS,6170330906,NDC,,,,inpatient,facility,1,GR,58.57,58.57,4.69,58.57,,,,,,,,,,,,,,58.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.57,,,percent of total billed charges,,,,,,,,,58.57,,,percent of total billed charges,,,29.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.14,,,percent of total billed charges,,,,,,,,,,,,,,,58.57,,,percent of total billed charges,,,49.78,,,percent of total billed charges,,,,,,,,,,,,,,,58.57,,,percent of total billed charges,,,31.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,58.57,,,percent of total billed charges,,,,,,,,,,,,,,,4.69,,,percent of total billed charges,,,58.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.51,,,percent of total billed charges,,
VINCRISTINE SULF INJ 1 MG,2500004260,CDM,636,RC,J9370,HCPCS,6170330906,NDC,,,,outpatient,facility,1,GR,58.57,58.57,4.48,548.68,,7.91,,,fee schedule,,,14.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,58.57,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,58.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,21.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.48,,,fee schedule,,,58.57,,,fee schedule,,,58.57,,,percent of total billed charges,,,,,,,,,58.57,,,percent of total billed charges,,,35.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,34.56,,,percent of total billed charges,,,548.68,,,per diem,,,58.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,58.57,,,percent of total billed charges,,,49.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.11,,,percent of total billed charges,,,58.57,,,percent of total billed charges,,,58.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.51,,,percent of total billed charges,,,47.39,,,percent of total billed charges,,,,,,,,,,,,,,,23.43,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,58.57,,,percent of total billed charges,,,58.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,58.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.69,,,percent of total billed charges,,,58.57,,,percent of total billed charges,,,,,,,,,,,,,,,58.57,,,percent of total billed charges,,,58.57,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,8.81,,,fee schedule,,,58.57,,,percent of total billed charges,,,58.57,,,percent of total billed charges,,,58.57,,,percent of total billed charges,,,,,,,,,41.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,34.51,,,percent of total billed charges,,
VINCRISTINE SULF INJ 1 MG,2500004260,CDM,636,RC,J9370,HCPCS,6170330906,NDC,495,EAPG,,outpatient,facility,1,GR,58.57,58.57,21.18,31.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.98,,,fee schedule,,,21.18,,,fee schedule,,,28.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,21.18,,,fee schedule,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VINCRISTINE SULF INJ 2 MG,2500004270,CDM,636,RC,J9370,HCPCS,6170330916,NDC,,,,inpatient,facility,2,GR,50.82,50.82,4.07,50.82,,,,,,,,,,,,,,50.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.82,,,percent of total billed charges,,,,,,,,,50.82,,,percent of total billed charges,,,25.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.49,,,percent of total billed charges,,,,,,,,,,,,,,,50.82,,,percent of total billed charges,,,43.2,,,percent of total billed charges,,,,,,,,,,,,,,,50.82,,,percent of total billed charges,,,26.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,50.82,,,percent of total billed charges,,,,,,,,,,,,,,,4.07,,,percent of total billed charges,,,50.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.94,,,percent of total billed charges,,
VINCRISTINE SULF INJ 2 MG,2500004270,CDM,636,RC,J9370,HCPCS,6170330916,NDC,,,,outpatient,facility,2,GR,50.82,50.82,4.07,548.68,,7.91,,,fee schedule,,,12.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,50.82,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,50.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,18.6,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.48,,,fee schedule,,,50.82,,,fee schedule,,,50.82,,,percent of total billed charges,,,,,,,,,50.82,,,percent of total billed charges,,,31.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,29.98,,,percent of total billed charges,,,548.68,,,per diem,,,50.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,50.82,,,percent of total billed charges,,,43.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.99,,,percent of total billed charges,,,50.82,,,percent of total billed charges,,,50.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.28,,,percent of total billed charges,,,41.12,,,percent of total billed charges,,,,,,,,,,,,,,,20.33,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,50.82,,,percent of total billed charges,,,50.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,50.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.07,,,percent of total billed charges,,,50.82,,,percent of total billed charges,,,,,,,,,,,,,,,50.82,,,percent of total billed charges,,,50.82,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,8.81,,,fee schedule,,,50.82,,,percent of total billed charges,,,50.82,,,percent of total billed charges,,,50.82,,,percent of total billed charges,,,,,,,,,35.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,29.94,,,percent of total billed charges,,
VINCRISTINE SULF INJ 2 MG,2500004270,CDM,636,RC,J9370,HCPCS,6170330916,NDC,495,EAPG,,outpatient,facility,2,GR,50.82,50.82,21.18,31.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.98,,,fee schedule,,,21.18,,,fee schedule,,,28.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,21.18,,,fee schedule,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VINORELBINE INJ 10 MG,2500004290,CDM,636,RC,J9390,HCPCS,2502120401,NDC,,,,inpatient,facility,1,UN,82.5,82.5,6.6,82.5,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,82.5,,,percent of total billed charges,,,42.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,70.12,,,percent of total billed charges,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,43.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.61,,,percent of total billed charges,,
VINORELBINE INJ 10 MG,2500004290,CDM,636,RC,J9390,HCPCS,2502120401,NDC,,,,outpatient,facility,1,UN,82.5,82.5,6.6,548.68,,8.5,,,fee schedule,,,20.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,82.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,30.2,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,23.23,,,fee schedule,,,82.5,,,fee schedule,,,82.5,,,percent of total billed charges,,,,,,,,,82.5,,,percent of total billed charges,,,50.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,48.68,,,percent of total billed charges,,,548.68,,,per diem,,,82.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,82.5,,,percent of total billed charges,,,70.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.82,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.65,,,percent of total billed charges,,,66.76,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,82.5,,,percent of total billed charges,,,82.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,82.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.6,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,8.5,,,fee schedule,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,57.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,48.61,,,percent of total billed charges,,
VINORELBINE INJ 10 MG,2500004290,CDM,636,RC,J9390,HCPCS,2502120401,NDC,430,EAPG,,outpatient,facility,1,UN,82.5,82.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VINORELBINE INJ 50 MG,2500004292,CDM,636,RC,J9390,HCPCS,2502120405,NDC,,,,inpatient,facility,5,UN,297,297,23.76,297,,,,,,,,,,,,,,297,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,297,,,percent of total billed charges,,,,,,,,,297,,,percent of total billed charges,,,151.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,,297,,,percent of total billed charges,,,252.45,,,percent of total billed charges,,,,,,,,,,,,,,,297,,,percent of total billed charges,,,157.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,297,,,percent of total billed charges,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,297,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,297,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.99,,,percent of total billed charges,,
VINORELBINE INJ 50 MG,2500004292,CDM,636,RC,J9390,HCPCS,2502120405,NDC,,,,outpatient,facility,5,UN,297,297,8.5,548.68,,8.5,,,fee schedule,,,72.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,297,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,297,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,108.7,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,23.23,,,fee schedule,,,297,,,fee schedule,,,297,,,percent of total billed charges,,,,,,,,,297,,,percent of total billed charges,,,182.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,175.23,,,percent of total billed charges,,,548.68,,,per diem,,,297,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,297,,,percent of total billed charges,,,252.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,157.74,,,percent of total billed charges,,,297,,,percent of total billed charges,,,297,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200.36,,,percent of total billed charges,,,240.33,,,percent of total billed charges,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,297,,,percent of total billed charges,,,297,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,297,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.76,,,percent of total billed charges,,,297,,,percent of total billed charges,,,,,,,,,,,,,,,297,,,percent of total billed charges,,,297,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,8.5,,,fee schedule,,,297,,,percent of total billed charges,,,297,,,percent of total billed charges,,,297,,,percent of total billed charges,,,,,,,,,208.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,174.99,,,percent of total billed charges,,
VINORELBINE INJ 50 MG,2500004292,CDM,636,RC,J9390,HCPCS,2502120405,NDC,430,EAPG,,outpatient,facility,5,UN,297,297,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE SULF PCA 30MG/30ML,2500004360,CDM,636,RC,J2270,HCPCS,7632919121,NDC,,,,inpatient,facility,30,UN,55.44,55.44,4.44,55.44,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,55.44,,,percent of total billed charges,,,28.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.26,,,percent of total billed charges,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,47.12,,,percent of total billed charges,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,29.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,4.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.67,,,percent of total billed charges,,
MORPHINE SULF PCA 30MG/30ML,2500004360,CDM,636,RC,J2270,HCPCS,7632919121,NDC,,,,outpatient,facility,30,UN,55.44,55.44,3.18,548.68,,39.31,,,percent of total billed charges,,,13.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,55.44,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,20.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.18,,,fee schedule,,,55.44,,,fee schedule,,,55.44,,,percent of total billed charges,,,,,,,,,55.44,,,percent of total billed charges,,,33.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,32.71,,,percent of total billed charges,,,548.68,,,per diem,,,55.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,55.44,,,percent of total billed charges,,,47.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.4,,,percent of total billed charges,,,44.86,,,percent of total billed charges,,,,,,,,,,,,,,,22.18,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,55.44,,,percent of total billed charges,,,55.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,55.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.37,,,fee schedule,,,55.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,38.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,32.67,,,percent of total billed charges,,
MORPHINE SULF PCA 30MG/30ML,2500004360,CDM,636,RC,J2270,HCPCS,7632919121,NDC,496,EAPG,,outpatient,facility,30,UN,55.44,55.44,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RITUXIMAB INJ 100 MG,2500004370,CDM,636,RC,J9312,HCPCS,5024205121,NDC,,,,inpatient,facility,10,GR,3100.41,3100.41,248.03,3100.41,,,,,,,,,,,,,,3100.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3100.41,,,percent of total billed charges,,,,,,,,,3100.41,,,percent of total billed charges,,,1583.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1860.25,,,percent of total billed charges,,,,,,,,,,,,,,,3100.41,,,percent of total billed charges,,,2635.35,,,percent of total billed charges,,,,,,,,,,,,,,,3100.41,,,percent of total billed charges,,,1646.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1240.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3100.41,,,percent of total billed charges,,,,,,,,,,,,,,,248.03,,,percent of total billed charges,,,3100.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3100.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1826.76,,,percent of total billed charges,,
RITUXIMAB INJ 100 MG,2500004370,CDM,636,RC,J9312,HCPCS,5024205121,NDC,,,,outpatient,facility,10,GR,3100.41,3100.41,56.13,3100.41,,78.87,,,fee schedule,,,,,,,,,3100.41,,,percent of total billed charges,,,100.83,,,fee schedule,,,95.39,,,fee schedule,,,,,,,,,95.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3100.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3100.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3100.41,,,fee schedule,,,3100.41,,,percent of total billed charges,,,,,,,,,3100.41,,,percent of total billed charges,,,1900.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2209.04,,,percent of total billed charges,,,,,,,,,,,,,,,79.2,,,fee schedule,,,79.2,,,fee schedule,,,79.2,,,fee schedule,,,,,,,,,1829.24,,,percent of total billed charges,,,548.68,,,per diem,,,3100.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3100.41,,,percent of total billed charges,,,2635.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1646.63,,,percent of total billed charges,,,3100.41,,,percent of total billed charges,,,3100.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2091.54,,,percent of total billed charges,,,2508.85,,,percent of total billed charges,,,,,,,,,,,,,,,1240.16,,,percent of total billed charges,,,,,,,,,202.09,,,fee schedule,,,145.42,,,fee schedule,,,,,,,,,3100.41,,,percent of total billed charges,,,,,,,,,,,,,,,248.03,,,percent of total billed charges,,,3100.41,,,percent of total billed charges,,,,,,,,,,,,,,,3100.41,,,percent of total billed charges,,,3100.41,,,percent of total billed charges,,,,,,,,,86.36,,,fee schedule,,,,,,,,,,,,,,,74.85,,,fee schedule,,,99.8,,,fee schedule,,,56.13,,,fee schedule,,,80.61,,,fee schedule,,,3100.41,,,percent of total billed charges,,,3100.41,,,percent of total billed charges,,,3100.41,,,percent of total billed charges,,,,,,,,,2173.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1550.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1826.76,,,percent of total billed charges,,
RITUXIMAB INJ 100 MG,2500004370,CDM,636,RC,J9312,HCPCS,5024205121,NDC,9186,APC,,outpatient,facility,10,GR,3100.41,3100.41,73.66,1134.75,,,,,,,,79.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,76.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.5,,,fee schedule,,,,,,,,,1134.75,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,76.73,,,fee schedule,,,,,,,,,,,,,,,80.57,,,fee schedule,,,80.57,,,fee schedule,,,,,,,,,76.73,,,fee schedule,,,76.73,,,fee schedule,,,80.57,,,fee schedule,,,,,,,,,,,,,,,115.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,76.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.66,,,fee schedule,,,82.1,,,fee schedule,,,80.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.73,,,fee schedule,,,76.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,79.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,76.73,,,fee schedule,,,,,,,,,95.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,95.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,76.73,,,fee schedule,,,76.73,,,fee schedule,,,,,,,,,,,,,,,76.73,,,fee schedule,,,,,,,,,76.73,,,fee schedule,,,79.03,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.73,,,fee schedule,,,,,,,,,,,,,,,79.8,,,fee schedule,,,76.73,,,fee schedule,,,,,,,,,76.73,,,fee schedule,,,,,,,,,76.73,,,fee schedule,,,80.57,,,fee schedule,,,,,,,,
RITUXIMAB INJ 100 MG,2500004370,CDM,636,RC,J9312,HCPCS,5024205121,NDC,462,EAPG,,outpatient,facility,10,GR,3100.41,3100.41,4530.01,6840.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6840.32,,,fee schedule,,,4530.01,,,fee schedule,,,6081.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RITUXIMAB INJ 500 MG,2500004372,CDM,636,RC,J9312,HCPCS,5024205306,NDC,,,,inpatient,facility,50,ML,15502.08,15502.08,1240.17,15502.08,,,,,,,,,,,,,,15502.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15502.08,,,percent of total billed charges,,,,,,,,,15502.08,,,percent of total billed charges,,,7915.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13203.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9301.25,,,percent of total billed charges,,,,,,,,,,,,,,,15502.08,,,percent of total billed charges,,,13176.77,,,percent of total billed charges,,,,,,,,,,,,,,,15502.08,,,percent of total billed charges,,,8233.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6200.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,15502.08,,,percent of total billed charges,,,,,,,,,,,,,,,1240.17,,,percent of total billed charges,,,15502.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15502.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9133.83,,,percent of total billed charges,,
RITUXIMAB INJ 500 MG,2500004372,CDM,636,RC,J9312,HCPCS,5024205306,NDC,,,,outpatient,facility,50,ML,15502.08,15502.08,56.13,15502.08,,78.87,,,fee schedule,,,,,,,,,15502.08,,,percent of total billed charges,,,100.83,,,fee schedule,,,95.39,,,fee schedule,,,,,,,,,95.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,15502.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,15502.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,15502.08,,,fee schedule,,,15502.08,,,percent of total billed charges,,,,,,,,,15502.08,,,percent of total billed charges,,,9501.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11045.23,,,percent of total billed charges,,,,,,,,,,,,,,,79.2,,,fee schedule,,,79.2,,,fee schedule,,,79.2,,,fee schedule,,,,,,,,,9146.23,,,percent of total billed charges,,,548.68,,,per diem,,,15502.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,15502.08,,,percent of total billed charges,,,13176.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8233.15,,,percent of total billed charges,,,15502.08,,,percent of total billed charges,,,15502.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10457.7,,,percent of total billed charges,,,12544.28,,,percent of total billed charges,,,,,,,,,,,,,,,6200.83,,,percent of total billed charges,,,,,,,,,202.09,,,fee schedule,,,145.42,,,fee schedule,,,,,,,,,15502.08,,,percent of total billed charges,,,,,,,,,,,,,,,1240.17,,,percent of total billed charges,,,15502.08,,,percent of total billed charges,,,,,,,,,,,,,,,15502.08,,,percent of total billed charges,,,15502.08,,,percent of total billed charges,,,,,,,,,86.36,,,fee schedule,,,,,,,,,,,,,,,74.85,,,fee schedule,,,99.8,,,fee schedule,,,56.13,,,fee schedule,,,80.61,,,fee schedule,,,15502.08,,,percent of total billed charges,,,15502.08,,,percent of total billed charges,,,15502.08,,,percent of total billed charges,,,,,,,,,10868.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7751.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9133.83,,,percent of total billed charges,,
RITUXIMAB INJ 500 MG,2500004372,CDM,636,RC,J9312,HCPCS,5024205306,NDC,9186,APC,,outpatient,facility,50,ML,15502.08,15502.08,73.66,5673.76,,,,,,,,79.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,76.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.5,,,fee schedule,,,,,,,,,5673.76,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,76.73,,,fee schedule,,,,,,,,,,,,,,,80.57,,,fee schedule,,,80.57,,,fee schedule,,,,,,,,,76.73,,,fee schedule,,,76.73,,,fee schedule,,,80.57,,,fee schedule,,,,,,,,,,,,,,,115.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,76.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.66,,,fee schedule,,,82.1,,,fee schedule,,,80.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.73,,,fee schedule,,,76.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,79.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,76.73,,,fee schedule,,,,,,,,,95.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,95.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,76.73,,,fee schedule,,,76.73,,,fee schedule,,,,,,,,,,,,,,,76.73,,,fee schedule,,,,,,,,,76.73,,,fee schedule,,,79.03,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.73,,,fee schedule,,,,,,,,,,,,,,,79.8,,,fee schedule,,,76.73,,,fee schedule,,,,,,,,,76.73,,,fee schedule,,,,,,,,,76.73,,,fee schedule,,,80.57,,,fee schedule,,,,,,,,
RITUXIMAB INJ 500 MG,2500004372,CDM,636,RC,J9312,HCPCS,5024205306,NDC,462,EAPG,,outpatient,facility,50,ML,15502.08,15502.08,4530.01,6840.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6840.32,,,fee schedule,,,4530.01,,,fee schedule,,,6081.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE SULF INJ 200MG,2500004401,CDM,636,RC,J2270,HCPCS,641603901,NDC,,,,inpatient,facility,20,UN,686.37,686.37,54.91,686.37,,,,,,,,,,,,,,686.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,686.37,,,percent of total billed charges,,,,,,,,,686.37,,,percent of total billed charges,,,350.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,584.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,411.82,,,percent of total billed charges,,,,,,,,,,,,,,,686.37,,,percent of total billed charges,,,583.41,,,percent of total billed charges,,,,,,,,,,,,,,,686.37,,,percent of total billed charges,,,364.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,686.37,,,percent of total billed charges,,,,,,,,,,,,,,,54.91,,,percent of total billed charges,,,686.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,686.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.41,,,percent of total billed charges,,
MORPHINE SULF INJ 200MG,2500004401,CDM,636,RC,J2270,HCPCS,641603901,NDC,,,,outpatient,facility,20,UN,686.37,686.37,3.18,686.37,,486.7,,,percent of total billed charges,,,167.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,686.37,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,686.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,251.21,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.18,,,fee schedule,,,686.37,,,fee schedule,,,686.37,,,percent of total billed charges,,,,,,,,,686.37,,,percent of total billed charges,,,420.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,489.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,404.96,,,percent of total billed charges,,,548.68,,,per diem,,,686.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,686.37,,,percent of total billed charges,,,583.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,364.53,,,percent of total billed charges,,,686.37,,,percent of total billed charges,,,686.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,463.03,,,percent of total billed charges,,,555.41,,,percent of total billed charges,,,,,,,,,,,,,,,274.55,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,686.37,,,percent of total billed charges,,,686.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,686.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,54.91,,,percent of total billed charges,,,686.37,,,percent of total billed charges,,,,,,,,,,,,,,,686.37,,,percent of total billed charges,,,686.37,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.37,,,fee schedule,,,686.37,,,percent of total billed charges,,,686.37,,,percent of total billed charges,,,686.37,,,percent of total billed charges,,,,,,,,,481.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,343.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,404.41,,,percent of total billed charges,,
MORPHINE SULF INJ 200MG,2500004401,CDM,636,RC,J2270,HCPCS,641603901,NDC,496,EAPG,,outpatient,facility,20,UN,686.37,686.37,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DARUNAVIR 800 MG TAB,2500004429,CDM,637,RC,5967656630,NDC,,,,,,inpatient,facility,800,UN,230.47,230.47,18.44,230.47,,,,,,,,,,,,,,230.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.47,,,percent of total billed charges,,,,,,,,,230.47,,,percent of total billed charges,,,117.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.28,,,percent of total billed charges,,,,,,,,,,,,,,,230.47,,,percent of total billed charges,,,195.9,,,percent of total billed charges,,,,,,,,,,,,,,,230.47,,,percent of total billed charges,,,122.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,230.47,,,percent of total billed charges,,,,,,,,,,,,,,,18.44,,,percent of total billed charges,,,230.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,230.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.79,,,percent of total billed charges,,
DARUNAVIR 800 MG TAB,2500004429,CDM,637,RC,5967656630,NDC,,,,,,outpatient,facility,800,UN,230.47,230.47,18.44,548.68,,163.43,,,percent of total billed charges,,,56.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,230.47,,,percent of total billed charges,,,144.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,162.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,162.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,230.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,84.35,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,230.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,230.47,,,fee schedule,,,230.47,,,percent of total billed charges,,,,,,,,,230.47,,,percent of total billed charges,,,141.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.21,,,percent of total billed charges,,,,,,,,,,,,,,,124.45,,,percent of total billed charges,,,119.84,,,percent of total billed charges,,,126.76,,,percent of total billed charges,,,,,,,,,135.98,,,percent of total billed charges,,,548.68,,,per diem,,,230.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,230.47,,,percent of total billed charges,,,195.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,122.4,,,percent of total billed charges,,,230.47,,,percent of total billed charges,,,230.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.48,,,percent of total billed charges,,,186.5,,,percent of total billed charges,,,,,,,,,,,,,,,92.19,,,percent of total billed charges,,,,,,,,,85.27,,,percent of total billed charges,,,85.27,,,percent of total billed charges,,,,,,,,,230.47,,,percent of total billed charges,,,230.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,230.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.44,,,percent of total billed charges,,,230.47,,,percent of total billed charges,,,,,,,,,,,,,,,230.47,,,percent of total billed charges,,,230.47,,,percent of total billed charges,,,,,,,,,214.38,,,percent of total billed charges,,,,,,,,,,,,,,,214.38,,,percent of total billed charges,,,214.38,,,percent of total billed charges,,,214.38,,,percent of total billed charges,,,172.85,,,percent of total billed charges,,,230.47,,,percent of total billed charges,,,230.47,,,percent of total billed charges,,,230.47,,,percent of total billed charges,,,,,,,,,161.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,135.79,,,percent of total billed charges,,
DARUNAVIR 800 MG TAB,2500004429,CDM,637,RC,5967656630,NDC,999,EAPG,,,,outpatient,facility,800,UN,230.47,230.47,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFUROXIME INJ 1.5 GM,2500004442,CDM,636,RC,J0697,HCPCS,143997722,NDC,,,,inpatient,facility,1500,UN,19.31,19.31,1.54,19.31,,,,,,,,,,,,,,19.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.31,,,percent of total billed charges,,,,,,,,,19.31,,,percent of total billed charges,,,9.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.59,,,percent of total billed charges,,,,,,,,,,,,,,,19.31,,,percent of total billed charges,,,16.41,,,percent of total billed charges,,,,,,,,,,,,,,,19.31,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,19.31,,,percent of total billed charges,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,19.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.38,,,percent of total billed charges,,
CEFUROXIME INJ 1.5 GM,2500004442,CDM,636,RC,J0697,HCPCS,143997722,NDC,,,,outpatient,facility,1500,UN,19.31,19.31,1.54,548.68,,13.69,,,percent of total billed charges,,,4.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,19.31,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,19.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.07,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.31,,,fee schedule,,,19.31,,,fee schedule,,,19.31,,,percent of total billed charges,,,,,,,,,19.31,,,percent of total billed charges,,,11.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,11.39,,,percent of total billed charges,,,548.68,,,per diem,,,19.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,19.31,,,percent of total billed charges,,,16.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.26,,,percent of total billed charges,,,19.31,,,percent of total billed charges,,,19.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.03,,,percent of total billed charges,,,15.63,,,percent of total billed charges,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,19.31,,,percent of total billed charges,,,19.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.54,,,percent of total billed charges,,,19.31,,,percent of total billed charges,,,,,,,,,,,,,,,19.31,,,percent of total billed charges,,,19.31,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.94,,,fee schedule,,,19.31,,,percent of total billed charges,,,19.31,,,percent of total billed charges,,,19.31,,,percent of total billed charges,,,,,,,,,13.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.65,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.38,,,percent of total billed charges,,
CEFUROXIME INJ 1.5 GM,2500004442,CDM,636,RC,J0697,HCPCS,143997722,NDC,496,EAPG,,outpatient,facility,1500,UN,19.31,19.31,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEUPROLIDE ACET DEPOT 22.5 MG,2500004460,CDM,636,RC,J9217,HCPCS,6293522305,NDC,,,,inpatient,facility,22.5,UN,4471.73,4471.73,357.74,4471.73,,,,,,,,,,,,,,4471.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4471.73,,,percent of total billed charges,,,,,,,,,4471.73,,,percent of total billed charges,,,2283.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3808.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2683.04,,,percent of total billed charges,,,,,,,,,,,,,,,4471.73,,,percent of total billed charges,,,3800.97,,,percent of total billed charges,,,,,,,,,,,,,,,4471.73,,,percent of total billed charges,,,2374.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1788.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4471.73,,,percent of total billed charges,,,,,,,,,,,,,,,357.74,,,percent of total billed charges,,,4471.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4471.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2634.74,,,percent of total billed charges,,
LEUPROLIDE ACET DEPOT 22.5 MG,2500004460,CDM,636,RC,J9217,HCPCS,6293522305,NDC,,,,outpatient,facility,22.5,UN,4471.73,4471.73,113.61,4471.73,,185.66,,,fee schedule,,,,,,,,,4471.73,,,percent of total billed charges,,,234.34,,,fee schedule,,,221.7,,,fee schedule,,,,,,,,,221.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4471.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,230.11,,,fee schedule,,,4471.73,,,fee schedule,,,4471.73,,,percent of total billed charges,,,,,,,,,4471.73,,,percent of total billed charges,,,2740.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3186.11,,,percent of total billed charges,,,,,,,,,,,,,,,181.3,,,fee schedule,,,181.3,,,fee schedule,,,181.3,,,fee schedule,,,,,,,,,2638.32,,,percent of total billed charges,,,548.68,,,per diem,,,4471.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4471.73,,,percent of total billed charges,,,3800.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2374.94,,,percent of total billed charges,,,4471.73,,,percent of total billed charges,,,4471.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3016.63,,,percent of total billed charges,,,3618.52,,,percent of total billed charges,,,,,,,,,,,,,,,1788.69,,,percent of total billed charges,,,,,,,,,409.02,,,fee schedule,,,294.32,,,fee schedule,,,,,,,,,4471.73,,,percent of total billed charges,,,,,,,,,,,,,,,357.74,,,percent of total billed charges,,,4471.73,,,percent of total billed charges,,,,,,,,,,,,,,,4471.73,,,percent of total billed charges,,,4471.73,,,percent of total billed charges,,,,,,,,,174.79,,,fee schedule,,,,,,,,,,,,,,,151.49,,,fee schedule,,,201.99,,,fee schedule,,,113.61,,,fee schedule,,,187.35,,,fee schedule,,,4471.73,,,percent of total billed charges,,,4471.73,,,percent of total billed charges,,,4471.73,,,percent of total billed charges,,,,,,,,,3135.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2235.86,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2634.74,,,percent of total billed charges,,
LEUPROLIDE ACET DEPOT 22.5 MG,2500004460,CDM,636,RC,J9217,HCPCS,6293522305,NDC,9217,APC,,outpatient,facility,22.5,UN,4471.73,4471.73,173.56,1636.65,,,,,,,,186.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.6,,,fee schedule,,,,,,,,,1636.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,189.83,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,180.79,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,,,,,,,,271.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.56,,,fee schedule,,,193.45,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,180.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,188.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,225.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,225.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,180.79,,,fee schedule,,,180.79,,,fee schedule,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,186.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,188.02,,,fee schedule,,,180.79,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,
LEUPROLIDE ACET DEPOT 22.5 MG,2500004460,CDM,636,RC,J9217,HCPCS,6293522305,NDC,434,EAPG,,outpatient,facility,22.5,UN,4471.73,4471.73,380.24,574.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,574.16,,,fee schedule,,,380.24,,,fee schedule,,,510.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,380.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,380.24,,,fee schedule,,,380.24,,,fee schedule,,,380.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,380.24,,,fee schedule,,,,,,,,,,,,,,,380.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA 4000 U,2500004490,CDM,636,RC,J0885,HCPCS,5967630401,NDC,,,,inpatient,facility,1,UN,352.77,352.77,28.22,352.77,,,,,,,,,,,,,,352.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.77,,,percent of total billed charges,,,,,,,,,352.77,,,percent of total billed charges,,,180.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,300.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.66,,,percent of total billed charges,,,,,,,,,,,,,,,352.77,,,percent of total billed charges,,,299.85,,,percent of total billed charges,,,,,,,,,,,,,,,352.77,,,percent of total billed charges,,,187.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,352.77,,,percent of total billed charges,,,,,,,,,,,,,,,28.22,,,percent of total billed charges,,,352.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.85,,,percent of total billed charges,,
EPOETIN ALFA 4000 U,2500004490,CDM,636,RC,J0885,HCPCS,5967630401,NDC,,,,outpatient,facility,1,UN,352.77,352.77,5.71,548.68,,8.27,,,fee schedule,,,,,,,,,352.77,,,percent of total billed charges,,,10.55,,,fee schedule,,,9.98,,,fee schedule,,,,,,,,,9.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,352.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.19,,,fee schedule,,,352.77,,,fee schedule,,,352.77,,,percent of total billed charges,,,,,,,,,352.77,,,percent of total billed charges,,,216.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,251.35,,,percent of total billed charges,,,,,,,,,,,,,,,8.89,,,fee schedule,,,8.89,,,fee schedule,,,8.89,,,fee schedule,,,,,,,,,208.13,,,percent of total billed charges,,,548.68,,,per diem,,,352.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,352.77,,,percent of total billed charges,,,299.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,187.36,,,percent of total billed charges,,,352.77,,,percent of total billed charges,,,352.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.98,,,percent of total billed charges,,,285.46,,,percent of total billed charges,,,,,,,,,,,,,,,141.11,,,percent of total billed charges,,,,,,,,,20.57,,,fee schedule,,,14.8,,,fee schedule,,,,,,,,,352.77,,,percent of total billed charges,,,,,,,,,,,,,,,28.22,,,percent of total billed charges,,,352.77,,,percent of total billed charges,,,,,,,,,,,,,,,352.77,,,percent of total billed charges,,,352.77,,,percent of total billed charges,,,,,,,,,8.79,,,fee schedule,,,,,,,,,,,,,,,7.62,,,fee schedule,,,10.16,,,fee schedule,,,5.71,,,fee schedule,,,8.44,,,fee schedule,,,352.77,,,percent of total billed charges,,,352.77,,,percent of total billed charges,,,352.77,,,percent of total billed charges,,,,,,,,,247.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,207.85,,,percent of total billed charges,,
EPOETIN ALFA 4000 U,2500004490,CDM,636,RC,J0885,HCPCS,5967630401,NDC,1686,APC,,outpatient,facility,1,UN,352.77,352.77,6.2,129.11,,,,,,,,6.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.52,,,fee schedule,,,,,,,,,129.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,6.78,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,6.46,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,,,,,,,,9.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.2,,,fee schedule,,,6.91,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,6.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,6.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,8.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,6.46,,,fee schedule,,,6.46,,,fee schedule,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,6.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,6.72,,,fee schedule,,,6.46,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,
EPOETIN ALFA 4000 U,2500004490,CDM,636,RC,J0885,HCPCS,5967630401,NDC,437,EAPG,,outpatient,facility,1,UN,352.77,352.77,156.28,235.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.98,,,fee schedule,,,156.28,,,fee schedule,,,209.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA 10000 U,2500004500,CDM,636,RC,J0885,HCPCS,5967631001,NDC,,,,inpatient,facility,1,UN,881.93,881.93,70.55,881.93,,,,,,,,,,,,,,881.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,881.93,,,percent of total billed charges,,,,,,,,,881.93,,,percent of total billed charges,,,450.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,751.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,529.16,,,percent of total billed charges,,,,,,,,,,,,,,,881.93,,,percent of total billed charges,,,749.64,,,percent of total billed charges,,,,,,,,,,,,,,,881.93,,,percent of total billed charges,,,468.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,881.93,,,percent of total billed charges,,,,,,,,,,,,,,,70.55,,,percent of total billed charges,,,881.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,881.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,519.63,,,percent of total billed charges,,
EPOETIN ALFA 10000 U,2500004500,CDM,636,RC,J0885,HCPCS,5967631001,NDC,,,,outpatient,facility,1,UN,881.93,881.93,5.71,881.93,,8.27,,,fee schedule,,,,,,,,,881.93,,,percent of total billed charges,,,10.55,,,fee schedule,,,9.98,,,fee schedule,,,,,,,,,9.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,881.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.19,,,fee schedule,,,881.93,,,fee schedule,,,881.93,,,percent of total billed charges,,,,,,,,,881.93,,,percent of total billed charges,,,540.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,628.38,,,percent of total billed charges,,,,,,,,,,,,,,,8.89,,,fee schedule,,,8.89,,,fee schedule,,,8.89,,,fee schedule,,,,,,,,,520.34,,,percent of total billed charges,,,548.68,,,per diem,,,881.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,881.93,,,percent of total billed charges,,,749.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,468.39,,,percent of total billed charges,,,881.93,,,percent of total billed charges,,,881.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,594.95,,,percent of total billed charges,,,713.66,,,percent of total billed charges,,,,,,,,,,,,,,,352.77,,,percent of total billed charges,,,,,,,,,20.57,,,fee schedule,,,14.8,,,fee schedule,,,,,,,,,881.93,,,percent of total billed charges,,,,,,,,,,,,,,,70.55,,,percent of total billed charges,,,881.93,,,percent of total billed charges,,,,,,,,,,,,,,,881.93,,,percent of total billed charges,,,881.93,,,percent of total billed charges,,,,,,,,,8.79,,,fee schedule,,,,,,,,,,,,,,,7.62,,,fee schedule,,,10.16,,,fee schedule,,,5.71,,,fee schedule,,,8.44,,,fee schedule,,,881.93,,,percent of total billed charges,,,881.93,,,percent of total billed charges,,,881.93,,,percent of total billed charges,,,,,,,,,618.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,440.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,519.63,,,percent of total billed charges,,
EPOETIN ALFA 10000 U,2500004500,CDM,636,RC,J0885,HCPCS,5967631001,NDC,1686,APC,,outpatient,facility,1,UN,881.93,881.93,6.2,322.79,,,,,,,,6.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.52,,,fee schedule,,,,,,,,,322.79,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,6.78,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,6.46,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,,,,,,,,9.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.2,,,fee schedule,,,6.91,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,6.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,6.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,8.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,6.46,,,fee schedule,,,6.46,,,fee schedule,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,6.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,6.72,,,fee schedule,,,6.46,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,
EPOETIN ALFA 10000 U,2500004500,CDM,636,RC,J0885,HCPCS,5967631001,NDC,437,EAPG,,outpatient,facility,1,UN,881.93,881.93,156.28,235.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.98,,,fee schedule,,,156.28,,,fee schedule,,,209.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA 20000 U,2500004510,CDM,636,RC,J0885,HCPCS,5551347810,NDC,,,,inpatient,facility,1,UN,780.3,780.3,62.42,780.3,,,,,,,,,,,,,,780.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,780.3,,,percent of total billed charges,,,,,,,,,780.3,,,percent of total billed charges,,,398.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,468.18,,,percent of total billed charges,,,,,,,,,,,,,,,780.3,,,percent of total billed charges,,,663.26,,,percent of total billed charges,,,,,,,,,,,,,,,780.3,,,percent of total billed charges,,,414.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,312.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,780.3,,,percent of total billed charges,,,,,,,,,,,,,,,62.42,,,percent of total billed charges,,,780.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,780.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,459.75,,,percent of total billed charges,,
EPOETIN ALFA 20000 U,2500004510,CDM,636,RC,J0885,HCPCS,5551347810,NDC,,,,outpatient,facility,1,UN,780.3,780.3,5.71,780.3,,8.27,,,fee schedule,,,,,,,,,780.3,,,percent of total billed charges,,,10.55,,,fee schedule,,,9.98,,,fee schedule,,,,,,,,,9.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,780.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.19,,,fee schedule,,,780.3,,,fee schedule,,,780.3,,,percent of total billed charges,,,,,,,,,780.3,,,percent of total billed charges,,,478.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.96,,,percent of total billed charges,,,,,,,,,,,,,,,8.89,,,fee schedule,,,8.89,,,fee schedule,,,8.89,,,fee schedule,,,,,,,,,460.38,,,percent of total billed charges,,,548.68,,,per diem,,,780.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,780.3,,,percent of total billed charges,,,663.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,414.42,,,percent of total billed charges,,,780.3,,,percent of total billed charges,,,780.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.39,,,percent of total billed charges,,,631.42,,,percent of total billed charges,,,,,,,,,,,,,,,312.12,,,percent of total billed charges,,,,,,,,,20.57,,,fee schedule,,,14.8,,,fee schedule,,,,,,,,,780.3,,,percent of total billed charges,,,,,,,,,,,,,,,62.42,,,percent of total billed charges,,,780.3,,,percent of total billed charges,,,,,,,,,,,,,,,780.3,,,percent of total billed charges,,,780.3,,,percent of total billed charges,,,,,,,,,8.79,,,fee schedule,,,,,,,,,,,,,,,7.62,,,fee schedule,,,10.16,,,fee schedule,,,5.71,,,fee schedule,,,8.44,,,fee schedule,,,780.3,,,percent of total billed charges,,,780.3,,,percent of total billed charges,,,780.3,,,percent of total billed charges,,,,,,,,,547.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,390.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,459.75,,,percent of total billed charges,,
EPOETIN ALFA 20000 U,2500004510,CDM,636,RC,J0885,HCPCS,5551347810,NDC,1686,APC,,outpatient,facility,1,UN,780.3,780.3,6.2,285.59,,,,,,,,6.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.52,,,fee schedule,,,,,,,,,285.59,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,6.78,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,6.46,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,,,,,,,,9.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.2,,,fee schedule,,,6.91,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,6.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,6.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,8.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,6.46,,,fee schedule,,,6.46,,,fee schedule,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,6.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,6.72,,,fee schedule,,,6.46,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,
EPOETIN ALFA 20000 U,2500004510,CDM,636,RC,J0885,HCPCS,5551347810,NDC,437,EAPG,,outpatient,facility,1,UN,780.3,780.3,156.28,235.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.98,,,fee schedule,,,156.28,,,fee schedule,,,209.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA 40000 U,2500004511,CDM,636,RC,J0885,HCPCS,5967634001,NDC,,,,inpatient,facility,1,ML,3527.7,3527.7,282.22,3527.7,,,,,,,,,,,,,,3527.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3527.7,,,percent of total billed charges,,,,,,,,,3527.7,,,percent of total billed charges,,,1801.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3004.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2116.62,,,percent of total billed charges,,,,,,,,,,,,,,,3527.7,,,percent of total billed charges,,,2998.54,,,percent of total billed charges,,,,,,,,,,,,,,,3527.7,,,percent of total billed charges,,,1873.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1411.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3527.7,,,percent of total billed charges,,,,,,,,,,,,,,,282.22,,,percent of total billed charges,,,3527.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3527.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.52,,,percent of total billed charges,,
EPOETIN ALFA 40000 U,2500004511,CDM,636,RC,J0885,HCPCS,5967634001,NDC,,,,outpatient,facility,1,ML,3527.7,3527.7,5.71,3527.7,,8.27,,,fee schedule,,,,,,,,,3527.7,,,percent of total billed charges,,,10.55,,,fee schedule,,,9.98,,,fee schedule,,,,,,,,,9.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3527.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.19,,,fee schedule,,,3527.7,,,fee schedule,,,3527.7,,,percent of total billed charges,,,,,,,,,3527.7,,,percent of total billed charges,,,2162.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2513.49,,,percent of total billed charges,,,,,,,,,,,,,,,8.89,,,fee schedule,,,8.89,,,fee schedule,,,8.89,,,fee schedule,,,,,,,,,2081.34,,,percent of total billed charges,,,548.68,,,per diem,,,3527.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3527.7,,,percent of total billed charges,,,2998.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1873.56,,,percent of total billed charges,,,3527.7,,,percent of total billed charges,,,3527.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2379.79,,,percent of total billed charges,,,2854.61,,,percent of total billed charges,,,,,,,,,,,,,,,1411.08,,,percent of total billed charges,,,,,,,,,20.57,,,fee schedule,,,14.8,,,fee schedule,,,,,,,,,3527.7,,,percent of total billed charges,,,,,,,,,,,,,,,282.22,,,percent of total billed charges,,,3527.7,,,percent of total billed charges,,,,,,,,,,,,,,,3527.7,,,percent of total billed charges,,,3527.7,,,percent of total billed charges,,,,,,,,,8.79,,,fee schedule,,,,,,,,,,,,,,,7.62,,,fee schedule,,,10.16,,,fee schedule,,,5.71,,,fee schedule,,,8.44,,,fee schedule,,,3527.7,,,percent of total billed charges,,,3527.7,,,percent of total billed charges,,,3527.7,,,percent of total billed charges,,,,,,,,,2473.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1763.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2078.52,,,percent of total billed charges,,
EPOETIN ALFA 40000 U,2500004511,CDM,636,RC,J0885,HCPCS,5967634001,NDC,1686,APC,,outpatient,facility,1,ML,3527.7,3527.7,6.2,1291.14,,,,,,,,6.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.52,,,fee schedule,,,,,,,,,1291.14,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,6.78,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,6.46,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,,,,,,,,9.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.2,,,fee schedule,,,6.91,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,6.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,6.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,8.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,6.46,,,fee schedule,,,6.46,,,fee schedule,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,6.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,6.72,,,fee schedule,,,6.46,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,
EPOETIN ALFA 40000 U,2500004511,CDM,636,RC,J0885,HCPCS,5967634001,NDC,437,EAPG,,outpatient,facility,1,ML,3527.7,3527.7,156.28,235.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.98,,,fee schedule,,,156.28,,,fee schedule,,,209.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOFLOXACIN INJ 250 MG,2500004600,CDM,636,RC,J1956,HCPCS,527194868,NDC,,,,inpatient,facility,10,UN,13.2,13.2,1.06,13.2,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,6.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,11.22,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,7.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.78,,,percent of total billed charges,,
LEVOFLOXACIN INJ 250 MG,2500004600,CDM,636,RC,J1956,HCPCS,527194868,NDC,,,,outpatient,facility,10,UN,13.2,13.2,0.97,548.68,,9.36,,,percent of total billed charges,,,3.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.83,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.09,,,fee schedule,,,13.2,,,fee schedule,,,13.2,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.79,,,percent of total billed charges,,,548.68,,,per diem,,,13.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.2,,,percent of total billed charges,,,11.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.01,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.9,,,percent of total billed charges,,,10.68,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13.2,,,percent of total billed charges,,,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.97,,,fee schedule,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,9.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.78,,,percent of total billed charges,,
LEVOFLOXACIN INJ 250 MG,2500004600,CDM,636,RC,J1956,HCPCS,527194868,NDC,496,EAPG,,outpatient,facility,10,UN,13.2,13.2,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOFLOXACIN INJ 500 MG,2500004602,CDM,636,RC,J1956,HCPCS,143972124,NDC,,,,inpatient,facility,100,UN,20.2,20.2,1.62,20.2,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,,,,,,,20.2,,,percent of total billed charges,,,10.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.12,,,percent of total billed charges,,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,17.17,,,percent of total billed charges,,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,10.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.9,,,percent of total billed charges,,
LEVOFLOXACIN INJ 500 MG,2500004602,CDM,636,RC,J1956,HCPCS,143972124,NDC,,,,outpatient,facility,100,UN,20.2,20.2,0.97,548.68,,14.32,,,percent of total billed charges,,,4.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,20.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.39,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.09,,,fee schedule,,,20.2,,,fee schedule,,,20.2,,,percent of total billed charges,,,,,,,,,20.2,,,percent of total billed charges,,,12.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,11.92,,,percent of total billed charges,,,548.68,,,per diem,,,20.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,20.2,,,percent of total billed charges,,,17.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.63,,,percent of total billed charges,,,16.35,,,percent of total billed charges,,,,,,,,,,,,,,,8.08,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,20.2,,,percent of total billed charges,,,20.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.62,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.97,,,fee schedule,,,20.2,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,,,,,,,14.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.9,,,percent of total billed charges,,
LEVOFLOXACIN INJ 500 MG,2500004602,CDM,636,RC,J1956,HCPCS,143972124,NDC,496,EAPG,,outpatient,facility,100,UN,20.2,20.2,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOFLOXACIN INJ 750 MG,2500004603,CDM,636,RC,J1956,HCPCS,409052835,NDC,,,,inpatient,facility,150,UN,11.85,11.85,0.95,11.85,,,,,,,,,,,,,,11.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.85,,,percent of total billed charges,,,,,,,,,11.85,,,percent of total billed charges,,,6.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.11,,,percent of total billed charges,,,,,,,,,,,,,,,11.85,,,percent of total billed charges,,,10.07,,,percent of total billed charges,,,,,,,,,,,,,,,11.85,,,percent of total billed charges,,,6.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11.85,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,11.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.98,,,percent of total billed charges,,
LEVOFLOXACIN INJ 750 MG,2500004603,CDM,636,RC,J1956,HCPCS,409052835,NDC,,,,outpatient,facility,150,UN,11.85,11.85,0.95,548.68,,8.4,,,percent of total billed charges,,,2.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,11.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,11.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.34,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.09,,,fee schedule,,,11.85,,,fee schedule,,,11.85,,,percent of total billed charges,,,,,,,,,11.85,,,percent of total billed charges,,,7.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,6.99,,,percent of total billed charges,,,548.68,,,per diem,,,11.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11.85,,,percent of total billed charges,,,10.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.29,,,percent of total billed charges,,,11.85,,,percent of total billed charges,,,11.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.99,,,percent of total billed charges,,,9.59,,,percent of total billed charges,,,,,,,,,,,,,,,4.74,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11.85,,,percent of total billed charges,,,11.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.95,,,percent of total billed charges,,,11.85,,,percent of total billed charges,,,,,,,,,,,,,,,11.85,,,percent of total billed charges,,,11.85,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.97,,,fee schedule,,,11.85,,,percent of total billed charges,,,11.85,,,percent of total billed charges,,,11.85,,,percent of total billed charges,,,,,,,,,8.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.98,,,percent of total billed charges,,
LEVOFLOXACIN INJ 750 MG,2500004603,CDM,636,RC,J1956,HCPCS,409052835,NDC,496,EAPG,,outpatient,facility,150,UN,11.85,11.85,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUMIN 25  50 ML,2500004690,CDM,636,RC,P9047,HCPCS,6898264301,NDC,,,,inpatient,facility,50,ML,189.42,189.42,15.15,189.42,,,,,,,,,,,,,,189.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.42,,,percent of total billed charges,,,,,,,,,189.42,,,percent of total billed charges,,,96.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.65,,,percent of total billed charges,,,,,,,,,,,,,,,189.42,,,percent of total billed charges,,,161.01,,,percent of total billed charges,,,,,,,,,,,,,,,189.42,,,percent of total billed charges,,,100.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,189.42,,,percent of total billed charges,,,,,,,,,,,,,,,15.15,,,percent of total billed charges,,,189.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,189.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.61,,,percent of total billed charges,,
ALBUMIN 25  50 ML,2500004690,CDM,636,RC,P9047,HCPCS,6898264301,NDC,,,,outpatient,facility,50,ML,189.42,189.42,15.15,548.68,,134.32,,,percent of total billed charges,,,46.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,189.42,,,percent of total billed charges,,,68.9,,,fee schedule,,,65.18,,,fee schedule,,,,,,,,,65.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,189.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,69.33,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,189.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,189.42,,,fee schedule,,,189.42,,,percent of total billed charges,,,,,,,,,189.42,,,percent of total billed charges,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.96,,,percent of total billed charges,,,,,,,,,,,,,,,45.9,,,fee schedule,,,45.9,,,fee schedule,,,45.9,,,fee schedule,,,,,,,,,111.76,,,percent of total billed charges,,,548.68,,,per diem,,,189.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,189.42,,,percent of total billed charges,,,161.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,100.6,,,percent of total billed charges,,,189.42,,,percent of total billed charges,,,189.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.78,,,percent of total billed charges,,,153.28,,,percent of total billed charges,,,,,,,,,,,,,,,75.77,,,percent of total billed charges,,,,,,,,,128.87,,,fee schedule,,,92.73,,,fee schedule,,,,,,,,,189.42,,,percent of total billed charges,,,189.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,189.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.15,,,percent of total billed charges,,,189.42,,,percent of total billed charges,,,,,,,,,,,,,,,189.42,,,percent of total billed charges,,,189.42,,,percent of total billed charges,,,,,,,,,55.07,,,fee schedule,,,,,,,,,,,,,,,47.73,,,fee schedule,,,63.64,,,fee schedule,,,35.8,,,fee schedule,,,55.08,,,fee schedule,,,189.42,,,percent of total billed charges,,,189.42,,,percent of total billed charges,,,189.42,,,percent of total billed charges,,,,,,,,,132.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,111.61,,,percent of total billed charges,,
ALBUMIN 25  50 ML,2500004690,CDM,636,RC,P9047,HCPCS,6898264301,NDC,999,EAPG,,outpatient,facility,50,ML,189.42,189.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUMIN 25  100 ML,2500004692,CDM,636,RC,P9047,HCPCS,6898264302,NDC,,,,inpatient,facility,100,ML,378.84,378.84,30.31,378.84,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,,,,,,,378.84,,,percent of total billed charges,,,193.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,322.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.3,,,percent of total billed charges,,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,322.01,,,percent of total billed charges,,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,201.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,30.31,,,percent of total billed charges,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.21,,,percent of total billed charges,,
ALBUMIN 25  100 ML,2500004692,CDM,636,RC,P9047,HCPCS,6898264302,NDC,,,,outpatient,facility,100,ML,378.84,378.84,30.31,548.68,,268.64,,,percent of total billed charges,,,92.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,378.84,,,percent of total billed charges,,,68.9,,,fee schedule,,,65.18,,,fee schedule,,,,,,,,,65.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,138.66,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,378.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,378.84,,,fee schedule,,,378.84,,,percent of total billed charges,,,,,,,,,378.84,,,percent of total billed charges,,,232.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,269.92,,,percent of total billed charges,,,,,,,,,,,,,,,45.9,,,fee schedule,,,45.9,,,fee schedule,,,45.9,,,fee schedule,,,,,,,,,223.52,,,percent of total billed charges,,,548.68,,,per diem,,,378.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,378.84,,,percent of total billed charges,,,322.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,201.2,,,percent of total billed charges,,,378.84,,,percent of total billed charges,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.57,,,percent of total billed charges,,,306.56,,,percent of total billed charges,,,,,,,,,,,,,,,151.54,,,percent of total billed charges,,,,,,,,,128.87,,,fee schedule,,,92.73,,,fee schedule,,,,,,,,,378.84,,,percent of total billed charges,,,378.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,378.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.31,,,percent of total billed charges,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,378.84,,,percent of total billed charges,,,,,,,,,55.07,,,fee schedule,,,,,,,,,,,,,,,47.73,,,fee schedule,,,63.64,,,fee schedule,,,35.8,,,fee schedule,,,55.08,,,fee schedule,,,378.84,,,percent of total billed charges,,,378.84,,,percent of total billed charges,,,378.84,,,percent of total billed charges,,,,,,,,,265.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,223.21,,,percent of total billed charges,,
ALBUMIN 25  100 ML,2500004692,CDM,636,RC,P9047,HCPCS,6898264302,NDC,999,EAPG,,outpatient,facility,100,ML,378.84,378.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUMIN 5   500 ML,2500004700,CDM,636,RC,P9045,HCPCS,6898262303,NDC,,,,inpatient,facility,500,ML,712.8,712.8,57.02,712.8,,,,,,,,,,,,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,712.8,,,percent of total billed charges,,,,,,,,,712.8,,,percent of total billed charges,,,363.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,607.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,427.68,,,percent of total billed charges,,,,,,,,,,,,,,,712.8,,,percent of total billed charges,,,605.88,,,percent of total billed charges,,,,,,,,,,,,,,,712.8,,,percent of total billed charges,,,378.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,285.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.98,,,percent of total billed charges,,
ALBUMIN 5   500 ML,2500004700,CDM,636,RC,P9045,HCPCS,6898262303,NDC,,,,outpatient,facility,500,ML,712.8,712.8,35.8,712.8,,505.45,,,percent of total billed charges,,,,,,,,,712.8,,,percent of total billed charges,,,68.9,,,fee schedule,,,65.18,,,fee schedule,,,,,,,,,65.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,712.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,712.8,,,fee schedule,,,712.8,,,percent of total billed charges,,,,,,,,,712.8,,,percent of total billed charges,,,436.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,507.87,,,percent of total billed charges,,,,,,,,,,,,,,,47.49,,,fee schedule,,,47.49,,,fee schedule,,,47.49,,,fee schedule,,,,,,,,,420.55,,,percent of total billed charges,,,548.68,,,per diem,,,712.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,712.8,,,percent of total billed charges,,,605.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,378.57,,,percent of total billed charges,,,712.8,,,percent of total billed charges,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480.85,,,percent of total billed charges,,,576.8,,,percent of total billed charges,,,,,,,,,,,,,,,285.12,,,percent of total billed charges,,,,,,,,,128.87,,,fee schedule,,,92.73,,,fee schedule,,,,,,,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,712.8,,,percent of total billed charges,,,712.8,,,percent of total billed charges,,,,,,,,,55.07,,,fee schedule,,,,,,,,,,,,,,,47.73,,,fee schedule,,,63.64,,,fee schedule,,,35.8,,,fee schedule,,,55.08,,,fee schedule,,,712.8,,,percent of total billed charges,,,712.8,,,percent of total billed charges,,,712.8,,,percent of total billed charges,,,,,,,,,499.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,356.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,419.98,,,percent of total billed charges,,
ALBUMIN 5   500 ML,2500004700,CDM,636,RC,P9045,HCPCS,6898262303,NDC,963,APC,,outpatient,facility,500,ML,712.8,712.8,50.96,260.88,,,,,,,,54.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.61,,,fee schedule,,,,,,,,,260.88,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,,,,,,,55.73,,,fee schedule,,,55.73,,,fee schedule,,,,,,,,,53.08,,,fee schedule,,,53.08,,,fee schedule,,,55.73,,,fee schedule,,,,,,,,,,,,,,,79.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.96,,,fee schedule,,,56.8,,,fee schedule,,,55.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,53.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,55.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,66.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,66.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,53.08,,,fee schedule,,,53.08,,,fee schedule,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,53.08,,,fee schedule,,,54.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,,,,,,,55.2,,,fee schedule,,,53.08,,,fee schedule,,,,,,,,,53.08,,,fee schedule,,,,,,,,,53.08,,,fee schedule,,,55.73,,,fee schedule,,,,,,,,
ALBUMIN 5   500 ML,2500004700,CDM,636,RC,P9045,HCPCS,6898262303,NDC,999,EAPG,,outpatient,facility,500,ML,712.8,712.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUMIN 5   250 ML,2500004703,CDM,636,RC,P9045,HCPCS,6898262302,NDC,,,,inpatient,facility,250,ML,228.69,228.69,18.3,228.69,,,,,,,,,,,,,,228.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.69,,,percent of total billed charges,,,,,,,,,228.69,,,percent of total billed charges,,,116.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.21,,,percent of total billed charges,,,,,,,,,,,,,,,228.69,,,percent of total billed charges,,,194.39,,,percent of total billed charges,,,,,,,,,,,,,,,228.69,,,percent of total billed charges,,,121.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,228.69,,,percent of total billed charges,,,,,,,,,,,,,,,18.3,,,percent of total billed charges,,,228.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,228.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.74,,,percent of total billed charges,,
ALBUMIN 5   250 ML,2500004703,CDM,636,RC,P9045,HCPCS,6898262302,NDC,,,,outpatient,facility,250,ML,228.69,228.69,18.3,548.68,,162.16,,,percent of total billed charges,,,,,,,,,228.69,,,percent of total billed charges,,,68.9,,,fee schedule,,,65.18,,,fee schedule,,,,,,,,,65.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,228.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,228.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,228.69,,,fee schedule,,,228.69,,,percent of total billed charges,,,,,,,,,228.69,,,percent of total billed charges,,,140.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.94,,,percent of total billed charges,,,,,,,,,,,,,,,47.49,,,fee schedule,,,47.49,,,fee schedule,,,47.49,,,fee schedule,,,,,,,,,134.93,,,percent of total billed charges,,,548.68,,,per diem,,,228.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,228.69,,,percent of total billed charges,,,194.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,121.46,,,percent of total billed charges,,,228.69,,,percent of total billed charges,,,228.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.27,,,percent of total billed charges,,,185.06,,,percent of total billed charges,,,,,,,,,,,,,,,91.48,,,percent of total billed charges,,,,,,,,,128.87,,,fee schedule,,,92.73,,,fee schedule,,,,,,,,,228.69,,,percent of total billed charges,,,,,,,,,,,,,,,18.3,,,percent of total billed charges,,,228.69,,,percent of total billed charges,,,,,,,,,,,,,,,228.69,,,percent of total billed charges,,,228.69,,,percent of total billed charges,,,,,,,,,55.07,,,fee schedule,,,,,,,,,,,,,,,47.73,,,fee schedule,,,63.64,,,fee schedule,,,35.8,,,fee schedule,,,55.08,,,fee schedule,,,228.69,,,percent of total billed charges,,,228.69,,,percent of total billed charges,,,228.69,,,percent of total billed charges,,,,,,,,,160.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,134.74,,,percent of total billed charges,,
ALBUMIN 5   250 ML,2500004703,CDM,636,RC,P9045,HCPCS,6898262302,NDC,963,APC,,outpatient,facility,250,ML,228.69,228.69,50.96,83.7,,,,,,,,54.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.61,,,fee schedule,,,,,,,,,83.7,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,,,,,,,55.73,,,fee schedule,,,55.73,,,fee schedule,,,,,,,,,53.08,,,fee schedule,,,53.08,,,fee schedule,,,55.73,,,fee schedule,,,,,,,,,,,,,,,79.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.96,,,fee schedule,,,56.8,,,fee schedule,,,55.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,53.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,55.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,66.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,66.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,53.08,,,fee schedule,,,53.08,,,fee schedule,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,53.08,,,fee schedule,,,54.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.08,,,fee schedule,,,,,,,,,,,,,,,55.2,,,fee schedule,,,53.08,,,fee schedule,,,,,,,,,53.08,,,fee schedule,,,,,,,,,53.08,,,fee schedule,,,55.73,,,fee schedule,,,,,,,,
ALBUMIN 5   250 ML,2500004703,CDM,636,RC,P9045,HCPCS,6898262302,NDC,999,EAPG,,outpatient,facility,250,ML,228.69,228.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACYCLOVIR  SOD 500 MG INJ,2500004852,CDM,636,RC,J0133,HCPCS,5515015410,NDC,,,,inpatient,facility,10,GR,52.8,52.8,4.22,52.8,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,52.8,,,percent of total billed charges,,,26.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,44.88,,,percent of total billed charges,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,28.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.11,,,percent of total billed charges,,
ACYCLOVIR  SOD 500 MG INJ,2500004852,CDM,636,RC,J0133,HCPCS,5515015410,NDC,,,,outpatient,facility,10,GR,52.8,52.8,0.04,548.68,,37.44,,,percent of total billed charges,,,12.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,52.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,19.32,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,52.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,52.8,,,fee schedule,,,52.8,,,percent of total billed charges,,,,,,,,,52.8,,,percent of total billed charges,,,32.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,31.15,,,percent of total billed charges,,,548.68,,,per diem,,,52.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,52.8,,,percent of total billed charges,,,44.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.04,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.62,,,percent of total billed charges,,,42.73,,,percent of total billed charges,,,,,,,,,,,,,,,21.12,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,52.8,,,percent of total billed charges,,,52.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,52.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.22,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.04,,,fee schedule,,,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,,,,,,,37.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,31.11,,,percent of total billed charges,,
ACYCLOVIR  SOD 500 MG INJ,2500004852,CDM,636,RC,J0133,HCPCS,5515015410,NDC,999,EAPG,,outpatient,facility,10,GR,52.8,52.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACYCLOVIR 5  CREAM 5 GM,2500004854,CDM,637,RC,187099445,NDC,,,,,,inpatient,facility,5,UN,660,660,52.8,660,,,,,,,,,,,,,,660,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,660,,,percent of total billed charges,,,,,,,,,660,,,percent of total billed charges,,,337,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,396,,,percent of total billed charges,,,,,,,,,,,,,,,660,,,percent of total billed charges,,,561,,,percent of total billed charges,,,,,,,,,,,,,,,660,,,percent of total billed charges,,,350.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,660,,,percent of total billed charges,,,,,,,,,,,,,,,52.8,,,percent of total billed charges,,,660,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,660,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.87,,,percent of total billed charges,,
ACYCLOVIR 5  CREAM 5 GM,2500004854,CDM,637,RC,187099445,NDC,,,,,,outpatient,facility,5,UN,660,660,52.8,660,,468.01,,,percent of total billed charges,,,161.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,660,,,percent of total billed charges,,,413.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,463.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,463.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,660,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,241.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,660,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,660,,,fee schedule,,,660,,,percent of total billed charges,,,,,,,,,660,,,percent of total billed charges,,,404.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,470.25,,,percent of total billed charges,,,,,,,,,,,,,,,356.4,,,percent of total billed charges,,,343.2,,,percent of total billed charges,,,363,,,percent of total billed charges,,,,,,,,,389.4,,,percent of total billed charges,,,548.68,,,per diem,,,660,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,660,,,percent of total billed charges,,,561,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,350.53,,,percent of total billed charges,,,660,,,percent of total billed charges,,,660,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,445.24,,,percent of total billed charges,,,534.07,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,244.2,,,percent of total billed charges,,,244.2,,,percent of total billed charges,,,,,,,,,660,,,percent of total billed charges,,,660,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,660,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,52.8,,,percent of total billed charges,,,660,,,percent of total billed charges,,,,,,,,,,,,,,,660,,,percent of total billed charges,,,660,,,percent of total billed charges,,,,,,,,,613.93,,,percent of total billed charges,,,,,,,,,,,,,,,613.93,,,percent of total billed charges,,,613.93,,,percent of total billed charges,,,613.93,,,percent of total billed charges,,,495,,,percent of total billed charges,,,660,,,percent of total billed charges,,,660,,,percent of total billed charges,,,660,,,percent of total billed charges,,,,,,,,,462.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,330,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,388.87,,,percent of total billed charges,,
ACYCLOVIR 5  CREAM 5 GM,2500004854,CDM,637,RC,187099445,NDC,999,EAPG,,,,outpatient,facility,5,UN,660,660,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AZITHROMYCIN 500 MG INJ,2500004880,CDM,636,RC,J0456,HCPCS,7043601982,NDC,,,,inpatient,facility,500,UN,57.09,57.09,4.57,57.09,,,,,,,,,,,,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.09,,,percent of total billed charges,,,,,,,,,57.09,,,percent of total billed charges,,,29.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.25,,,percent of total billed charges,,,,,,,,,,,,,,,57.09,,,percent of total billed charges,,,48.53,,,percent of total billed charges,,,,,,,,,,,,,,,57.09,,,percent of total billed charges,,,30.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,,4.57,,,percent of total billed charges,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.64,,,percent of total billed charges,,
AZITHROMYCIN 500 MG INJ,2500004880,CDM,636,RC,J0456,HCPCS,7043601982,NDC,,,,outpatient,facility,500,UN,57.09,57.09,2.26,548.68,,40.48,,,percent of total billed charges,,,13.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,57.09,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,20.89,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.46,,,fee schedule,,,57.09,,,fee schedule,,,57.09,,,percent of total billed charges,,,,,,,,,57.09,,,percent of total billed charges,,,34.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,33.68,,,percent of total billed charges,,,548.68,,,per diem,,,57.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,57.09,,,percent of total billed charges,,,48.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.32,,,percent of total billed charges,,,57.09,,,percent of total billed charges,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.51,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,22.84,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,57.09,,,percent of total billed charges,,,57.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,57.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.57,,,percent of total billed charges,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,,57.09,,,percent of total billed charges,,,57.09,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.26,,,fee schedule,,,57.09,,,percent of total billed charges,,,57.09,,,percent of total billed charges,,,57.09,,,percent of total billed charges,,,,,,,,,40.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,33.64,,,percent of total billed charges,,
AZITHROMYCIN 500 MG INJ,2500004880,CDM,636,RC,J0456,HCPCS,7043601982,NDC,496,EAPG,,outpatient,facility,500,UN,57.09,57.09,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AZTREONAM 1000 MG INJ,2500004892,CDM,636,RC,J0457,HCPCS,6332340120,NDC,,,,inpatient,facility,1,UN,119.06,119.06,9.52,119.06,,,,,,,,,,,,,,119.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.06,,,percent of total billed charges,,,,,,,,,119.06,,,percent of total billed charges,,,60.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.44,,,percent of total billed charges,,,,,,,,,,,,,,,119.06,,,percent of total billed charges,,,101.2,,,percent of total billed charges,,,,,,,,,,,,,,,119.06,,,percent of total billed charges,,,63.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,119.06,,,percent of total billed charges,,,,,,,,,,,,,,,9.52,,,percent of total billed charges,,,119.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.15,,,percent of total billed charges,,
AZTREONAM 1000 MG INJ,2500004892,CDM,636,RC,J0457,HCPCS,6332340120,NDC,,,,outpatient,facility,1,UN,119.06,119.06,2.21,548.68,,84.43,,,percent of total billed charges,,,29.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,119.06,,,percent of total billed charges,,,2.76,,,fee schedule,,,2.62,,,fee schedule,,,,,,,,,2.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,119.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,43.58,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,119.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,119.06,,,fee schedule,,,119.06,,,percent of total billed charges,,,,,,,,,119.06,,,percent of total billed charges,,,72.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,70.25,,,percent of total billed charges,,,548.68,,,per diem,,,119.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,119.06,,,percent of total billed charges,,,101.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.23,,,percent of total billed charges,,,119.06,,,percent of total billed charges,,,119.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.32,,,percent of total billed charges,,,96.34,,,percent of total billed charges,,,,,,,,,,,,,,,47.62,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,119.06,,,percent of total billed charges,,,119.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,119.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.52,,,percent of total billed charges,,,119.06,,,percent of total billed charges,,,,,,,,,,,,,,,119.06,,,percent of total billed charges,,,119.06,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.21,,,fee schedule,,,119.06,,,percent of total billed charges,,,119.06,,,percent of total billed charges,,,119.06,,,percent of total billed charges,,,,,,,,,83.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,70.15,,,percent of total billed charges,,
AZTREONAM 1000 MG INJ,2500004892,CDM,636,RC,J0457,HCPCS,6332340120,NDC,435,EAPG,,outpatient,facility,1,UN,119.06,119.06,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AZTREONAM 2000 MG INJ,2500004894,CDM,636,RC,J0457,HCPCS,6332340220,NDC,,,,inpatient,facility,2,UN,241.92,241.92,19.35,241.92,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,241.92,,,percent of total billed charges,,,123.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.15,,,percent of total billed charges,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,205.63,,,percent of total billed charges,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,128.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,19.35,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.54,,,percent of total billed charges,,
AZTREONAM 2000 MG INJ,2500004894,CDM,636,RC,J0457,HCPCS,6332340220,NDC,,,,outpatient,facility,2,UN,241.92,241.92,2.21,548.68,,171.55,,,percent of total billed charges,,,59.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,241.92,,,percent of total billed charges,,,2.76,,,fee schedule,,,2.62,,,fee schedule,,,,,,,,,2.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,88.54,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,241.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,241.92,,,fee schedule,,,241.92,,,percent of total billed charges,,,,,,,,,241.92,,,percent of total billed charges,,,148.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,142.73,,,percent of total billed charges,,,548.68,,,per diem,,,241.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,241.92,,,percent of total billed charges,,,205.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,128.48,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.2,,,percent of total billed charges,,,195.76,,,percent of total billed charges,,,,,,,,,,,,,,,96.77,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,241.92,,,percent of total billed charges,,,241.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,241.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.35,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.21,,,fee schedule,,,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,169.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,142.54,,,percent of total billed charges,,
AZTREONAM 2000 MG INJ,2500004894,CDM,636,RC,J0457,HCPCS,6332340220,NDC,435,EAPG,,outpatient,facility,2,UN,241.92,241.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLINDAMYCIN PHOS INJ 300 MG,2500004960,CDM,636,RC,J0736,HCPCS,781328809,NDC,,,,inpatient,facility,100,UN,32.47,32.47,2.6,32.47,,,,,,,,,,,,,,32.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.47,,,percent of total billed charges,,,,,,,,,32.47,,,percent of total billed charges,,,16.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.48,,,percent of total billed charges,,,,,,,,,,,,,,,32.47,,,percent of total billed charges,,,27.6,,,percent of total billed charges,,,,,,,,,,,,,,,32.47,,,percent of total billed charges,,,17.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,32.47,,,percent of total billed charges,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,32.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.13,,,percent of total billed charges,,
CLINDAMYCIN PHOS INJ 300 MG,2500004960,CDM,636,RC,J0736,HCPCS,781328809,NDC,,,,outpatient,facility,100,UN,32.47,32.47,2.49,548.68,,23.02,,,percent of total billed charges,,,7.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,32.47,,,percent of total billed charges,,,3.1,,,fee schedule,,,2.93,,,fee schedule,,,,,,,,,2.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,32.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.88,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,32.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,32.47,,,fee schedule,,,32.47,,,percent of total billed charges,,,,,,,,,32.47,,,percent of total billed charges,,,19.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,19.16,,,percent of total billed charges,,,548.68,,,per diem,,,32.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,32.47,,,percent of total billed charges,,,27.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.24,,,percent of total billed charges,,,32.47,,,percent of total billed charges,,,32.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.9,,,percent of total billed charges,,,26.27,,,percent of total billed charges,,,,,,,,,,,,,,,12.99,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,32.47,,,percent of total billed charges,,,32.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,32.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.6,,,percent of total billed charges,,,32.47,,,percent of total billed charges,,,,,,,,,,,,,,,32.47,,,percent of total billed charges,,,32.47,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.49,,,fee schedule,,,32.47,,,percent of total billed charges,,,32.47,,,percent of total billed charges,,,32.47,,,percent of total billed charges,,,,,,,,,22.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,19.13,,,percent of total billed charges,,
CLINDAMYCIN PHOS INJ 300 MG,2500004960,CDM,636,RC,J0736,HCPCS,781328809,NDC,435,EAPG,,outpatient,facility,100,UN,32.47,32.47,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLINDAMYCIN PHOS INJ 600 MG,2500004962,CDM,636,RC,J0736,HCPCS,781328909,NDC,,,,inpatient,facility,100,UN,48.97,48.97,3.92,48.97,,,,,,,,,,,,,,48.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.97,,,percent of total billed charges,,,,,,,,,48.97,,,percent of total billed charges,,,25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.38,,,percent of total billed charges,,,,,,,,,,,,,,,48.97,,,percent of total billed charges,,,41.62,,,percent of total billed charges,,,,,,,,,,,,,,,48.97,,,percent of total billed charges,,,26.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,48.97,,,percent of total billed charges,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,48.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.85,,,percent of total billed charges,,
CLINDAMYCIN PHOS INJ 600 MG,2500004962,CDM,636,RC,J0736,HCPCS,781328909,NDC,,,,outpatient,facility,100,UN,48.97,48.97,2.49,548.68,,34.72,,,percent of total billed charges,,,11.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,48.97,,,percent of total billed charges,,,3.1,,,fee schedule,,,2.93,,,fee schedule,,,,,,,,,2.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,48.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,17.92,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,48.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,48.97,,,fee schedule,,,48.97,,,percent of total billed charges,,,,,,,,,48.97,,,percent of total billed charges,,,30.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,28.89,,,percent of total billed charges,,,548.68,,,per diem,,,48.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,48.97,,,percent of total billed charges,,,41.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.01,,,percent of total billed charges,,,48.97,,,percent of total billed charges,,,48.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.04,,,percent of total billed charges,,,39.63,,,percent of total billed charges,,,,,,,,,,,,,,,19.59,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,48.97,,,percent of total billed charges,,,48.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,48.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.92,,,percent of total billed charges,,,48.97,,,percent of total billed charges,,,,,,,,,,,,,,,48.97,,,percent of total billed charges,,,48.97,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.49,,,fee schedule,,,48.97,,,percent of total billed charges,,,48.97,,,percent of total billed charges,,,48.97,,,percent of total billed charges,,,,,,,,,34.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,28.85,,,percent of total billed charges,,
CLINDAMYCIN PHOS INJ 600 MG,2500004962,CDM,636,RC,J0736,HCPCS,781328909,NDC,435,EAPG,,outpatient,facility,100,UN,48.97,48.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLINDAMYCIN PHOS INJ 900 MG,2500004964,CDM,636,RC,J0736,HCPCS,781329009,NDC,,,,inpatient,facility,50,UN,19.51,19.51,1.56,19.51,,,,,,,,,,,,,,19.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.51,,,percent of total billed charges,,,,,,,,,19.51,,,percent of total billed charges,,,9.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.71,,,percent of total billed charges,,,,,,,,,,,,,,,19.51,,,percent of total billed charges,,,16.58,,,percent of total billed charges,,,,,,,,,,,,,,,19.51,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,19.51,,,percent of total billed charges,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,19.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.5,,,percent of total billed charges,,
CLINDAMYCIN PHOS INJ 900 MG,2500004964,CDM,636,RC,J0736,HCPCS,781329009,NDC,,,,outpatient,facility,50,UN,19.51,19.51,1.56,548.68,,13.83,,,percent of total billed charges,,,4.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,19.51,,,percent of total billed charges,,,3.1,,,fee schedule,,,2.93,,,fee schedule,,,,,,,,,2.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,19.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.14,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,19.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,19.51,,,fee schedule,,,19.51,,,percent of total billed charges,,,,,,,,,19.51,,,percent of total billed charges,,,11.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,11.51,,,percent of total billed charges,,,548.68,,,per diem,,,19.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,19.51,,,percent of total billed charges,,,16.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,19.51,,,percent of total billed charges,,,19.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.16,,,percent of total billed charges,,,15.79,,,percent of total billed charges,,,,,,,,,,,,,,,7.8,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,19.51,,,percent of total billed charges,,,19.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.56,,,percent of total billed charges,,,19.51,,,percent of total billed charges,,,,,,,,,,,,,,,19.51,,,percent of total billed charges,,,19.51,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.49,,,fee schedule,,,19.51,,,percent of total billed charges,,,19.51,,,percent of total billed charges,,,19.51,,,percent of total billed charges,,,,,,,,,13.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.5,,,percent of total billed charges,,
CLINDAMYCIN PHOS INJ 900 MG,2500004964,CDM,636,RC,J0736,HCPCS,781329009,NDC,435,EAPG,,outpatient,facility,50,UN,19.51,19.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUCONAZOLE INJ UPTO 200MG,2500005020,CDM,636,RC,J1450,HCPCS,2502111382,NDC,,,,inpatient,facility,1,UN,29.7,29.7,2.38,29.7,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,29.7,,,percent of total billed charges,,,15.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,25.24,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,15.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.5,,,percent of total billed charges,,
FLUCONAZOLE INJ UPTO 200MG,2500005020,CDM,636,RC,J1450,HCPCS,2502111382,NDC,,,,outpatient,facility,1,UN,29.7,29.7,2.38,548.68,,21.06,,,percent of total billed charges,,,7.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,29.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,29.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,29.7,,,fee schedule,,,29.7,,,percent of total billed charges,,,,,,,,,29.7,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,17.52,,,percent of total billed charges,,,548.68,,,per diem,,,29.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,29.7,,,percent of total billed charges,,,25.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.77,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.04,,,percent of total billed charges,,,24.03,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,29.7,,,percent of total billed charges,,,29.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.38,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.54,,,fee schedule,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,20.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.5,,,percent of total billed charges,,
FLUCONAZOLE INJ UPTO 200MG,2500005020,CDM,636,RC,J1450,HCPCS,2502111382,NDC,999,EAPG,,outpatient,facility,1,UN,29.7,29.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUCONAZOLE INJ 400MG,2500005023,CDM,636,RC,J1450,HCPCS,2502118487,NDC,,,,inpatient,facility,200,UN,46.2,46.2,3.7,46.2,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,23.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.72,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,39.27,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,24.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.22,,,percent of total billed charges,,
FLUCONAZOLE INJ 400MG,2500005023,CDM,636,RC,J1450,HCPCS,2502118487,NDC,,,,outpatient,facility,200,UN,46.2,46.2,2.54,548.68,,32.76,,,percent of total billed charges,,,11.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,46.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,16.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,46.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,46.2,,,fee schedule,,,46.2,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,28.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,27.26,,,percent of total billed charges,,,548.68,,,per diem,,,46.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,46.2,,,percent of total billed charges,,,39.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.54,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.17,,,percent of total billed charges,,,37.39,,,percent of total billed charges,,,,,,,,,,,,,,,18.48,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,46.2,,,percent of total billed charges,,,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.54,,,fee schedule,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,32.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,27.22,,,percent of total billed charges,,
FLUCONAZOLE INJ 400MG,2500005023,CDM,636,RC,J1450,HCPCS,2502118487,NDC,999,EAPG,,outpatient,facility,200,UN,46.2,46.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HAEMOPH B POLY CONJ10MCG/0.5ML,2500005040,CDM,636,RC,90648,CPT,4928154503,NDC,,,,inpatient,facility,0.5,UN,38.61,38.61,3.09,38.61,,,,,,,,,,,,,,38.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.61,,,percent of total billed charges,,,,,,,,,38.61,,,percent of total billed charges,,,19.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.17,,,percent of total billed charges,,,,,,,,,,,,,,,38.61,,,percent of total billed charges,,,32.82,,,percent of total billed charges,,,,,,,,,,,,,,,38.61,,,percent of total billed charges,,,20.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,38.61,,,percent of total billed charges,,,,,,,,,,,,,,,3.09,,,percent of total billed charges,,,38.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.75,,,percent of total billed charges,,
HAEMOPH B POLY CONJ10MCG/0.5ML,2500005040,CDM,636,RC,90648,CPT,4928154503,NDC,,,,outpatient,facility,0.5,UN,38.61,38.61,3.09,548.68,,27.38,,,percent of total billed charges,,,9.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,38.61,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,38.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,14.13,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,26.68,,,fee schedule,,,38.61,,,fee schedule,,,38.61,,,percent of total billed charges,,,,,,,,,38.61,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,22.78,,,percent of total billed charges,,,548.68,,,per diem,,,38.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,38.61,,,percent of total billed charges,,,32.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.51,,,percent of total billed charges,,,38.61,,,percent of total billed charges,,,38.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.05,,,percent of total billed charges,,,31.24,,,percent of total billed charges,,,,,,,,,,,,,,,15.44,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,38.61,,,percent of total billed charges,,,38.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,38.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.09,,,percent of total billed charges,,,38.61,,,percent of total billed charges,,,,,,,,,,,,,,,38.61,,,percent of total billed charges,,,38.61,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,28.94,,,fee schedule,,,38.61,,,percent of total billed charges,,,38.61,,,percent of total billed charges,,,38.61,,,percent of total billed charges,,,,,,,,,27.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,,,,,,service not payable
HAEMOPH B POLY CONJ10MCG/0.5ML,2500005040,CDM,636,RC,90648,CPT,4928154503,NDC,999,EAPG,,outpatient,facility,0.5,UN,38.61,38.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INFLIXIMAB EXC BIOS INJ 100MG,2500005052,CDM,636,RC,J1745,HCPCS,5789403001,NDC,,,,inpatient,facility,10,ML,3853.8,3853.8,308.3,3853.8,,,,,,,,,,,,,,3853.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3853.8,,,percent of total billed charges,,,,,,,,,3853.8,,,percent of total billed charges,,,1967.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3282.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2312.28,,,percent of total billed charges,,,,,,,,,,,,,,,3853.8,,,percent of total billed charges,,,3275.73,,,percent of total billed charges,,,,,,,,,,,,,,,3853.8,,,percent of total billed charges,,,2046.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1541.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3853.8,,,percent of total billed charges,,,,,,,,,,,,,,,308.3,,,percent of total billed charges,,,3853.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3853.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2270.66,,,percent of total billed charges,,
INFLIXIMAB EXC BIOS INJ 100MG,2500005052,CDM,636,RC,J1745,HCPCS,5789403001,NDC,,,,outpatient,facility,10,ML,3853.8,3853.8,23.9,3853.8,,2732.73,,,percent of total billed charges,,,,,,,,,3853.8,,,percent of total billed charges,,,41.16,,,fee schedule,,,38.94,,,fee schedule,,,,,,,,,38.94,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3853.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,69.16,,,fee schedule,,,3853.8,,,fee schedule,,,3853.8,,,percent of total billed charges,,,,,,,,,3853.8,,,percent of total billed charges,,,2361.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2745.83,,,percent of total billed charges,,,,,,,,,,,,,,,32.16,,,fee schedule,,,32.16,,,fee schedule,,,32.16,,,fee schedule,,,,,,,,,2273.74,,,percent of total billed charges,,,548.68,,,per diem,,,3853.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3853.8,,,percent of total billed charges,,,3275.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2046.75,,,percent of total billed charges,,,3853.8,,,percent of total billed charges,,,3853.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2599.77,,,percent of total billed charges,,,3118.49,,,percent of total billed charges,,,,,,,,,,,,,,,1541.52,,,percent of total billed charges,,,,,,,,,86.04,,,fee schedule,,,61.92,,,fee schedule,,,,,,,,,3853.8,,,percent of total billed charges,,,,,,,,,,,,,,,308.3,,,percent of total billed charges,,,3853.8,,,percent of total billed charges,,,,,,,,,,,,,,,3853.8,,,percent of total billed charges,,,3853.8,,,percent of total billed charges,,,,,,,,,36.77,,,fee schedule,,,,,,,,,,,,,,,31.87,,,fee schedule,,,42.49,,,fee schedule,,,23.9,,,fee schedule,,,32.9,,,fee schedule,,,3853.8,,,percent of total billed charges,,,3853.8,,,percent of total billed charges,,,3853.8,,,percent of total billed charges,,,,,,,,,2701.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1926.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2270.66,,,percent of total billed charges,,
INFLIXIMAB EXC BIOS INJ 100MG,2500005052,CDM,636,RC,J1745,HCPCS,5789403001,NDC,7043,APC,,outpatient,facility,10,ML,3853.8,3853.8,29.31,1410.49,,,,,,,,31.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,30.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.84,,,fee schedule,,,,,,,,,1410.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,30.53,,,fee schedule,,,,,,,,,,,,,,,32.06,,,fee schedule,,,32.06,,,fee schedule,,,,,,,,,30.53,,,fee schedule,,,30.53,,,fee schedule,,,32.06,,,fee schedule,,,,,,,,,,,,,,,45.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,30.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.31,,,fee schedule,,,32.67,,,fee schedule,,,32.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.53,,,fee schedule,,,30.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,31.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,30.53,,,fee schedule,,,,,,,,,38.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,38.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,30.53,,,fee schedule,,,30.53,,,fee schedule,,,,,,,,,,,,,,,30.53,,,fee schedule,,,,,,,,,30.53,,,fee schedule,,,31.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.53,,,fee schedule,,,,,,,,,,,,,,,31.75,,,fee schedule,,,30.53,,,fee schedule,,,,,,,,,30.53,,,fee schedule,,,,,,,,,30.53,,,fee schedule,,,32.06,,,fee schedule,,,,,,,,
INFLIXIMAB EXC BIOS INJ 100MG,2500005052,CDM,636,RC,J1745,HCPCS,5789403001,NDC,444,EAPG,,outpatient,facility,10,ML,3853.8,3853.8,1304.36,1969.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1969.58,,,fee schedule,,,1304.36,,,fee schedule,,,1750.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IRON DEXTRAN 100MG (165-INFED),2500005062,CDM,636,RC,J1750,HCPCS,23608210,NDC,,,,inpatient,facility,2,UN,117.18,117.18,9.37,117.18,,,,,,,,,,,,,,117.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.18,,,percent of total billed charges,,,,,,,,,117.18,,,percent of total billed charges,,,59.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.31,,,percent of total billed charges,,,,,,,,,,,,,,,117.18,,,percent of total billed charges,,,99.6,,,percent of total billed charges,,,,,,,,,,,,,,,117.18,,,percent of total billed charges,,,62.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,117.18,,,percent of total billed charges,,,,,,,,,,,,,,,9.37,,,percent of total billed charges,,,117.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,117.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.04,,,percent of total billed charges,,
IRON DEXTRAN 100MG (165-INFED),2500005062,CDM,636,RC,J1750,HCPCS,23608210,NDC,,,,outpatient,facility,2,UN,117.18,117.18,9.37,548.68,,83.09,,,percent of total billed charges,,,,,,,,,117.18,,,percent of total billed charges,,,23.35,,,fee schedule,,,22.09,,,fee schedule,,,,,,,,,22.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,117.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.42,,,fee schedule,,,117.18,,,fee schedule,,,117.18,,,percent of total billed charges,,,,,,,,,117.18,,,percent of total billed charges,,,71.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.49,,,percent of total billed charges,,,,,,,,,,,,,,,17.32,,,fee schedule,,,17.32,,,fee schedule,,,17.32,,,fee schedule,,,,,,,,,69.14,,,percent of total billed charges,,,548.68,,,per diem,,,117.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,117.18,,,percent of total billed charges,,,99.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.23,,,percent of total billed charges,,,117.18,,,percent of total billed charges,,,117.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.05,,,percent of total billed charges,,,94.82,,,percent of total billed charges,,,,,,,,,,,,,,,46.87,,,percent of total billed charges,,,,,,,,,40.61,,,fee schedule,,,29.23,,,fee schedule,,,,,,,,,117.18,,,percent of total billed charges,,,,,,,,,,,,,,,9.37,,,percent of total billed charges,,,117.18,,,percent of total billed charges,,,,,,,,,,,,,,,117.18,,,percent of total billed charges,,,117.18,,,percent of total billed charges,,,,,,,,,17.36,,,fee schedule,,,,,,,,,,,,,,,15.05,,,fee schedule,,,20.06,,,fee schedule,,,11.28,,,fee schedule,,,18.67,,,fee schedule,,,117.18,,,percent of total billed charges,,,117.18,,,percent of total billed charges,,,117.18,,,percent of total billed charges,,,,,,,,,82.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,69.04,,,percent of total billed charges,,
IRON DEXTRAN 100MG (165-INFED),2500005062,CDM,636,RC,J1750,HCPCS,23608210,NDC,1237,APC,,outpatient,facility,2,UN,117.18,117.18,16.7,42.89,,,,,,,,17.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,17.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.57,,,fee schedule,,,,,,,,,42.89,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,fee schedule,,,,,,,,,,,,,,,18.27,,,fee schedule,,,18.27,,,fee schedule,,,,,,,,,17.4,,,fee schedule,,,17.4,,,fee schedule,,,18.27,,,fee schedule,,,,,,,,,,,,,,,26.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.7,,,fee schedule,,,18.62,,,fee schedule,,,18.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,fee schedule,,,17.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,18.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,fee schedule,,,,,,,,,21.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,17.4,,,fee schedule,,,17.4,,,fee schedule,,,,,,,,,,,,,,,17.4,,,fee schedule,,,,,,,,,17.4,,,fee schedule,,,17.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,fee schedule,,,,,,,,,,,,,,,18.1,,,fee schedule,,,17.4,,,fee schedule,,,,,,,,,17.4,,,fee schedule,,,,,,,,,17.4,,,fee schedule,,,18.27,,,fee schedule,,,,,,,,
IRON DEXTRAN 100MG (165-INFED),2500005062,CDM,636,RC,J1750,HCPCS,23608210,NDC,436,EAPG,,outpatient,facility,2,UN,117.18,117.18,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCTREOTIDE ACET IV SC 100 MCG,2500005107,CDM,636,RC,J2354,HCPCS,6745724501,NDC,,,,inpatient,facility,1,UN,31.28,31.28,2.5,31.28,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,31.28,,,percent of total billed charges,,,15.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.77,,,percent of total billed charges,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,26.59,,,percent of total billed charges,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,16.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.43,,,percent of total billed charges,,
OCTREOTIDE ACET IV SC 100 MCG,2500005107,CDM,636,RC,J2354,HCPCS,6745724501,NDC,,,,outpatient,facility,1,UN,31.28,31.28,0.94,548.68,,22.18,,,percent of total billed charges,,,7.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,31.28,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.45,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,31.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,31.28,,,fee schedule,,,31.28,,,percent of total billed charges,,,,,,,,,31.28,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,18.46,,,percent of total billed charges,,,548.68,,,per diem,,,31.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,31.28,,,percent of total billed charges,,,26.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.61,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.1,,,percent of total billed charges,,,25.31,,,percent of total billed charges,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,31.28,,,percent of total billed charges,,,31.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.5,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.94,,,fee schedule,,,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,21.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.43,,,percent of total billed charges,,
OCTREOTIDE ACET IV SC 100 MCG,2500005107,CDM,636,RC,J2354,HCPCS,6745724501,NDC,496,EAPG,,outpatient,facility,1,UN,31.28,31.28,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCTREOTIDE ACET IV SC 500 MCG,2500005108,CDM,636,RC,J2354,HCPCS,6745724501,NDC,,,,inpatient,facility,50,ML,163.98,163.98,13.12,163.98,,,,,,,,,,,,,,163.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.98,,,percent of total billed charges,,,,,,,,,163.98,,,percent of total billed charges,,,83.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.39,,,percent of total billed charges,,,,,,,,,,,,,,,163.98,,,percent of total billed charges,,,139.38,,,percent of total billed charges,,,,,,,,,,,,,,,163.98,,,percent of total billed charges,,,87.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,163.98,,,percent of total billed charges,,,,,,,,,,,,,,,13.12,,,percent of total billed charges,,,163.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,163.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.62,,,percent of total billed charges,,
OCTREOTIDE ACET IV SC 500 MCG,2500005108,CDM,636,RC,J2354,HCPCS,6745724501,NDC,,,,outpatient,facility,50,ML,163.98,163.98,0.94,548.68,,116.28,,,percent of total billed charges,,,40.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,163.98,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,163.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,60.02,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,163.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,163.98,,,fee schedule,,,163.98,,,percent of total billed charges,,,,,,,,,163.98,,,percent of total billed charges,,,100.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,96.75,,,percent of total billed charges,,,548.68,,,per diem,,,163.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,163.98,,,percent of total billed charges,,,139.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,87.09,,,percent of total billed charges,,,163.98,,,percent of total billed charges,,,163.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.62,,,percent of total billed charges,,,132.69,,,percent of total billed charges,,,,,,,,,,,,,,,65.59,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,163.98,,,percent of total billed charges,,,163.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,163.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.12,,,percent of total billed charges,,,163.98,,,percent of total billed charges,,,,,,,,,,,,,,,163.98,,,percent of total billed charges,,,163.98,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.94,,,fee schedule,,,163.98,,,percent of total billed charges,,,163.98,,,percent of total billed charges,,,163.98,,,percent of total billed charges,,,,,,,,,114.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,96.62,,,percent of total billed charges,,
OCTREOTIDE ACET IV SC 500 MCG,2500005108,CDM,636,RC,J2354,HCPCS,6745724501,NDC,496,EAPG,,outpatient,facility,50,ML,163.98,163.98,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIPERCILLIN TAZOBACT 2.25 INJ,2500005142,CDM,636,RC,J2543,HCPCS,5515011930,NDC,,,,inpatient,facility,2.25,UN,47.85,47.85,3.83,47.85,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,47.85,,,percent of total billed charges,,,24.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.71,,,percent of total billed charges,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,40.67,,,percent of total billed charges,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,25.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.19,,,percent of total billed charges,,
PIPERCILLIN TAZOBACT 2.25 INJ,2500005142,CDM,636,RC,J2543,HCPCS,5515011930,NDC,,,,outpatient,facility,2.25,UN,47.85,47.85,1.22,548.68,,33.93,,,percent of total billed charges,,,11.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,47.85,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,17.51,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,47.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,47.85,,,fee schedule,,,47.85,,,percent of total billed charges,,,,,,,,,47.85,,,percent of total billed charges,,,29.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,28.23,,,percent of total billed charges,,,548.68,,,per diem,,,47.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,47.85,,,percent of total billed charges,,,40.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.41,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.28,,,percent of total billed charges,,,38.72,,,percent of total billed charges,,,,,,,,,,,,,,,19.14,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,47.85,,,percent of total billed charges,,,47.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,47.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.83,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.22,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,,,,,,,33.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,28.19,,,percent of total billed charges,,
PIPERCILLIN TAZOBACT 2.25 INJ,2500005142,CDM,636,RC,J2543,HCPCS,5515011930,NDC,496,EAPG,,outpatient,facility,2.25,UN,47.85,47.85,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIPERCILLIN TAZOBACT 3.375 INJ,2500005144,CDM,636,RC,J2543,HCPCS,6050561574,NDC,,,,inpatient,facility,3.375,UN,56.69,56.69,4.54,56.69,,,,,,,,,,,,,,56.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.69,,,percent of total billed charges,,,,,,,,,56.69,,,percent of total billed charges,,,28.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,,percent of total billed charges,,,,,,,,,,,,,,,56.69,,,percent of total billed charges,,,48.19,,,percent of total billed charges,,,,,,,,,,,,,,,56.69,,,percent of total billed charges,,,30.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,56.69,,,percent of total billed charges,,,,,,,,,,,,,,,4.54,,,percent of total billed charges,,,56.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.4,,,percent of total billed charges,,
PIPERCILLIN TAZOBACT 3.375 INJ,2500005144,CDM,636,RC,J2543,HCPCS,6050561574,NDC,,,,outpatient,facility,3.375,UN,56.69,56.69,1.22,548.68,,40.2,,,percent of total billed charges,,,13.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,56.69,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,56.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,20.75,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,56.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,56.69,,,fee schedule,,,56.69,,,percent of total billed charges,,,,,,,,,56.69,,,percent of total billed charges,,,34.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,33.45,,,percent of total billed charges,,,548.68,,,per diem,,,56.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,56.69,,,percent of total billed charges,,,48.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.11,,,percent of total billed charges,,,56.69,,,percent of total billed charges,,,56.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.24,,,percent of total billed charges,,,45.87,,,percent of total billed charges,,,,,,,,,,,,,,,22.68,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,56.69,,,percent of total billed charges,,,56.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,56.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.54,,,percent of total billed charges,,,56.69,,,percent of total billed charges,,,,,,,,,,,,,,,56.69,,,percent of total billed charges,,,56.69,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.22,,,fee schedule,,,56.69,,,percent of total billed charges,,,56.69,,,percent of total billed charges,,,56.69,,,percent of total billed charges,,,,,,,,,39.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,33.4,,,percent of total billed charges,,
PIPERCILLIN TAZOBACT 3.375 INJ,2500005144,CDM,636,RC,J2543,HCPCS,6050561574,NDC,496,EAPG,,outpatient,facility,3.375,UN,56.69,56.69,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SILDENAFIL CITRATE 20 MG TAB,2500005185,CDM,637,RC,S0090,HCPCS,904667106,NDC,,,,inpatient,facility,20,UN,2.77,2.77,0.22,2.77,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,
SILDENAFIL CITRATE 20 MG TAB,2500005185,CDM,637,RC,S0090,HCPCS,904667106,NDC,,,,outpatient,facility,20,UN,2.77,2.77,0.22,548.68,,1.96,,,percent of total billed charges,,,0.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.77,,,percent of total billed charges,,,0.39,,,fee schedule,,,0.37,,,fee schedule,,,,,,,,,0.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.77,,,fee schedule,,,2.77,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,1.63,,,percent of total billed charges,,,548.68,,,per diem,,,2.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.77,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,2.77,,,fee schedule,,,2.77,,,fee schedule,,,,,,,,,2.77,,,percent of total billed charges,,,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.22,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,2.77,,,fee schedule,,,,,,,,,,,,,,,2.77,,,fee schedule,,,2.77,,,fee schedule,,,2.77,,,fee schedule,,,2.77,,,fee schedule,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.63,,,percent of total billed charges,,
SILDENAFIL CITRATE 20 MG TAB,2500005185,CDM,637,RC,S0090,HCPCS,904667106,NDC,999,EAPG,,outpatient,facility,20,UN,2.77,2.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD FERRIC GLUCON  62.5 MG INJ,2500005190,CDM,636,RC,J2916,HCPCS,143957010,NDC,,,,inpatient,facility,5,ML,104.94,104.94,8.4,104.94,,,,,,,,,,,,,,104.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.94,,,percent of total billed charges,,,,,,,,,104.94,,,percent of total billed charges,,,53.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.96,,,percent of total billed charges,,,,,,,,,,,,,,,104.94,,,percent of total billed charges,,,89.2,,,percent of total billed charges,,,,,,,,,,,,,,,104.94,,,percent of total billed charges,,,55.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,104.94,,,percent of total billed charges,,,,,,,,,,,,,,,8.4,,,percent of total billed charges,,,104.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,104.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.83,,,percent of total billed charges,,
SOD FERRIC GLUCON  62.5 MG INJ,2500005190,CDM,636,RC,J2916,HCPCS,143957010,NDC,,,,outpatient,facility,5,ML,104.94,104.94,2.22,548.68,,74.41,,,percent of total billed charges,,,25.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,104.94,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,104.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,38.41,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.29,,,fee schedule,,,104.94,,,fee schedule,,,104.94,,,percent of total billed charges,,,,,,,,,104.94,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,61.91,,,percent of total billed charges,,,548.68,,,per diem,,,104.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,104.94,,,percent of total billed charges,,,89.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.73,,,percent of total billed charges,,,104.94,,,percent of total billed charges,,,104.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.79,,,percent of total billed charges,,,84.92,,,percent of total billed charges,,,,,,,,,,,,,,,41.98,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,104.94,,,percent of total billed charges,,,104.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,104.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.4,,,percent of total billed charges,,,104.94,,,percent of total billed charges,,,,,,,,,,,,,,,104.94,,,percent of total billed charges,,,104.94,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.22,,,fee schedule,,,104.94,,,percent of total billed charges,,,104.94,,,percent of total billed charges,,,104.94,,,percent of total billed charges,,,,,,,,,73.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,61.83,,,percent of total billed charges,,
SOD FERRIC GLUCON  62.5 MG INJ,2500005190,CDM,636,RC,J2916,HCPCS,143957010,NDC,435,EAPG,,outpatient,facility,5,ML,104.94,104.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIMETHOPRIM/SULFAMET INJ 10ML,2500005230,CDM,250,RC,J3490,HCPCS,703951491,NDC,,,,inpatient,facility,10,UN,30.65,30.65,2.45,30.65,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,,,,,,,30.65,,,percent of total billed charges,,,15.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.39,,,percent of total billed charges,,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,26.05,,,percent of total billed charges,,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,16.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,30.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.06,,,percent of total billed charges,,
TRIMETHOPRIM/SULFAMET INJ 10ML,2500005230,CDM,250,RC,J3490,HCPCS,703951491,NDC,,,,outpatient,facility,10,UN,30.65,30.65,1.2,548.68,,21.73,,,percent of total billed charges,,,7.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,30.65,,,percent of total billed charges,,,19.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,21.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,21.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,30.65,,,fee schedule,,,30.65,,,percent of total billed charges,,,,,,,,,30.65,,,percent of total billed charges,,,18.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.84,,,percent of total billed charges,,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,30.65,,,percent of total billed charges,,,30.65,,,percent of total billed charges,,,,,,,,,18.08,,,percent of total billed charges,,,548.68,,,per diem,,,30.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,30.65,,,percent of total billed charges,,,26.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.28,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.68,,,percent of total billed charges,,,24.8,,,percent of total billed charges,,,,,,,,,,,,,,,12.26,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,30.65,,,percent of total billed charges,,,30.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.45,,,percent of total billed charges,,,30.65,,,percent of total billed charges,,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,30.65,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,22.99,,,percent of total billed charges,,,30.65,,,percent of total billed charges,,,30.65,,,percent of total billed charges,,,30.65,,,percent of total billed charges,,,,,,,,,21.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.06,,,percent of total billed charges,,
TRIMETHOPRIM/SULFAMET INJ 10ML,2500005230,CDM,250,RC,J3490,HCPCS,703951491,NDC,435,EAPG,,outpatient,facility,10,UN,30.65,30.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TOBRAMYCIN INH 300MG,2500005270,CDM,637,RC,J7682,HCPCS,6516291446,NDC,,,,inpatient,facility,5,UN,466.49,466.49,37.32,466.49,,,,,,,,,,,,,,466.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.49,,,percent of total billed charges,,,,,,,,,466.49,,,percent of total billed charges,,,238.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.89,,,percent of total billed charges,,,,,,,,,,,,,,,466.49,,,percent of total billed charges,,,396.52,,,percent of total billed charges,,,,,,,,,,,,,,,466.49,,,percent of total billed charges,,,247.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,466.49,,,percent of total billed charges,,,,,,,,,,,,,,,37.32,,,percent of total billed charges,,,466.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,466.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.86,,,percent of total billed charges,,
TOBRAMYCIN INH 300MG,2500005270,CDM,637,RC,J7682,HCPCS,6516291446,NDC,,,,outpatient,facility,5,UN,466.49,466.49,15.87,548.68,,330.79,,,percent of total billed charges,,,113.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,466.49,,,percent of total billed charges,,,22.12,,,fee schedule,,,20.93,,,fee schedule,,,,,,,,,20.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,466.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,170.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,90.36,,,fee schedule,,,15.95,,,fee schedule,,,466.49,,,percent of total billed charges,,,,,,,,,466.49,,,percent of total billed charges,,,285.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.37,,,percent of total billed charges,,,,,,,,,,,,,,,21.79,,,fee schedule,,,21.79,,,fee schedule,,,21.79,,,fee schedule,,,,,,,,,275.23,,,percent of total billed charges,,,548.68,,,per diem,,,466.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,466.49,,,percent of total billed charges,,,396.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,247.75,,,percent of total billed charges,,,466.49,,,percent of total billed charges,,,466.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,314.69,,,percent of total billed charges,,,377.48,,,percent of total billed charges,,,,,,,,,,,,,,,186.6,,,percent of total billed charges,,,,,,,,,57.13,,,fee schedule,,,41.11,,,fee schedule,,,,,,,,,466.49,,,percent of total billed charges,,,466.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,466.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,37.32,,,percent of total billed charges,,,466.49,,,percent of total billed charges,,,,,,,,,,,,,,,466.49,,,percent of total billed charges,,,466.49,,,percent of total billed charges,,,,,,,,,24.41,,,fee schedule,,,,,,,,,,,,,,,21.16,,,fee schedule,,,28.21,,,fee schedule,,,15.87,,,fee schedule,,,17.68,,,fee schedule,,,466.49,,,percent of total billed charges,,,466.49,,,percent of total billed charges,,,466.49,,,percent of total billed charges,,,,,,,,,327.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,274.86,,,percent of total billed charges,,
TOBRAMYCIN INH 300MG,2500005270,CDM,637,RC,J7682,HCPCS,6516291446,NDC,435,EAPG,,outpatient,facility,5,UN,466.49,466.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXRAZOXANE INJ 500 MG,2500005330,CDM,636,RC,J1190,HCPCS,7631011001,NDC,,,,inpatient,facility,500,GR,1514.7,1514.7,121.18,1514.7,,,,,,,,,,,,,,1514.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1514.7,,,percent of total billed charges,,,,,,,,,1514.7,,,percent of total billed charges,,,773.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1290.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,908.82,,,percent of total billed charges,,,,,,,,,,,,,,,1514.7,,,percent of total billed charges,,,1287.5,,,percent of total billed charges,,,,,,,,,,,,,,,1514.7,,,percent of total billed charges,,,804.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,605.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1514.7,,,percent of total billed charges,,,,,,,,,,,,,,,121.18,,,percent of total billed charges,,,1514.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1514.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,892.46,,,percent of total billed charges,,
DEXRAZOXANE INJ 500 MG,2500005330,CDM,636,RC,J1190,HCPCS,7631011001,NDC,,,,outpatient,facility,500,GR,1514.7,1514.7,91.09,1514.7,,91.09,,,fee schedule,,,,,,,,,1514.7,,,percent of total billed charges,,,130.67,,,fee schedule,,,123.62,,,fee schedule,,,,,,,,,123.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1514.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1514.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1514.7,,,fee schedule,,,1514.7,,,percent of total billed charges,,,,,,,,,1514.7,,,percent of total billed charges,,,928.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1079.22,,,percent of total billed charges,,,,,,,,,,,,,,,108.01,,,fee schedule,,,108.01,,,fee schedule,,,108.01,,,fee schedule,,,,,,,,,893.67,,,percent of total billed charges,,,548.68,,,per diem,,,1514.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1514.7,,,percent of total billed charges,,,1287.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,804.46,,,percent of total billed charges,,,1514.7,,,percent of total billed charges,,,1514.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1021.82,,,percent of total billed charges,,,1225.7,,,percent of total billed charges,,,,,,,,,,,,,,,605.88,,,percent of total billed charges,,,,,,,,,385.01,,,fee schedule,,,277.05,,,fee schedule,,,,,,,,,1514.7,,,percent of total billed charges,,,,,,,,,,,,,,,121.18,,,percent of total billed charges,,,1514.7,,,percent of total billed charges,,,,,,,,,,,,,,,1514.7,,,percent of total billed charges,,,1514.7,,,percent of total billed charges,,,,,,,,,164.54,,,fee schedule,,,,,,,,,,,,,,,142.61,,,fee schedule,,,190.14,,,fee schedule,,,106.95,,,fee schedule,,,104.47,,,fee schedule,,,1514.7,,,percent of total billed charges,,,1514.7,,,percent of total billed charges,,,1514.7,,,percent of total billed charges,,,,,,,,,1061.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,757.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,892.46,,,percent of total billed charges,,
DEXRAZOXANE INJ 500 MG,2500005330,CDM,636,RC,J1190,HCPCS,7631011001,NDC,726,APC,,outpatient,facility,500,GR,1514.7,1514.7,77.64,554.38,,,,,,,,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,80.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.69,,,fee schedule,,,,,,,,,554.38,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,80.88,,,fee schedule,,,,,,,,,,,,,,,84.92,,,fee schedule,,,84.92,,,fee schedule,,,,,,,,,80.88,,,fee schedule,,,80.88,,,fee schedule,,,84.92,,,fee schedule,,,,,,,,,,,,,,,121.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,80.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.64,,,fee schedule,,,86.54,,,fee schedule,,,84.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.88,,,fee schedule,,,80.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,84.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,80.88,,,fee schedule,,,,,,,,,101.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,101.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,80.88,,,fee schedule,,,80.88,,,fee schedule,,,,,,,,,,,,,,,80.88,,,fee schedule,,,,,,,,,80.88,,,fee schedule,,,83.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.88,,,fee schedule,,,,,,,,,,,,,,,84.12,,,fee schedule,,,80.88,,,fee schedule,,,,,,,,,80.88,,,fee schedule,,,,,,,,,80.88,,,fee schedule,,,84.92,,,fee schedule,,,,,,,,
DEXRAZOXANE INJ 500 MG,2500005330,CDM,636,RC,J1190,HCPCS,7631011001,NDC,441,EAPG,,outpatient,facility,500,GR,1514.7,1514.7,878.39,1326.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1326.37,,,fee schedule,,,878.39,,,fee schedule,,,1179.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.39,,,fee schedule,,,878.39,,,fee schedule,,,878.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,878.39,,,fee schedule,,,,,,,,,,,,,,,878.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DORNASE ALPHA INH 2.5 MG,2500005340,CDM,637,RC,J7639,HCPCS,5024210040,NDC,,,,inpatient,facility,2.5,UN,428.6,428.6,34.29,428.6,,,,,,,,,,,,,,428.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,428.6,,,percent of total billed charges,,,,,,,,,428.6,,,percent of total billed charges,,,218.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,365.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.16,,,percent of total billed charges,,,,,,,,,,,,,,,428.6,,,percent of total billed charges,,,364.31,,,percent of total billed charges,,,,,,,,,,,,,,,428.6,,,percent of total billed charges,,,227.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,428.6,,,percent of total billed charges,,,,,,,,,,,,,,,34.29,,,percent of total billed charges,,,428.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,428.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.53,,,percent of total billed charges,,
DORNASE ALPHA INH 2.5 MG,2500005340,CDM,637,RC,J7639,HCPCS,5024210040,NDC,,,,outpatient,facility,2.5,UN,428.6,428.6,31.92,548.68,,303.92,,,percent of total billed charges,,,104.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,428.6,,,percent of total billed charges,,,69.37,,,fee schedule,,,65.62,,,fee schedule,,,,,,,,,65.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,428.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,156.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,31.92,,,fee schedule,,,53.48,,,fee schedule,,,428.6,,,percent of total billed charges,,,,,,,,,428.6,,,percent of total billed charges,,,262.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,305.38,,,percent of total billed charges,,,,,,,,,,,,,,,52.08,,,fee schedule,,,52.08,,,fee schedule,,,52.08,,,fee schedule,,,,,,,,,252.87,,,percent of total billed charges,,,548.68,,,per diem,,,428.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,428.6,,,percent of total billed charges,,,364.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,227.63,,,percent of total billed charges,,,428.6,,,percent of total billed charges,,,428.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,289.13,,,percent of total billed charges,,,346.82,,,percent of total billed charges,,,,,,,,,,,,,,,171.44,,,percent of total billed charges,,,,,,,,,123.24,,,fee schedule,,,88.68,,,fee schedule,,,,,,,,,428.6,,,percent of total billed charges,,,428.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,428.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,34.29,,,percent of total billed charges,,,428.6,,,percent of total billed charges,,,,,,,,,,,,,,,428.6,,,percent of total billed charges,,,428.6,,,percent of total billed charges,,,,,,,,,52.67,,,fee schedule,,,,,,,,,,,,,,,45.65,,,fee schedule,,,60.86,,,fee schedule,,,34.24,,,fee schedule,,,55.45,,,fee schedule,,,428.6,,,percent of total billed charges,,,428.6,,,percent of total billed charges,,,428.6,,,percent of total billed charges,,,,,,,,,300.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,252.53,,,percent of total billed charges,,
DORNASE ALPHA INH 2.5 MG,2500005340,CDM,637,RC,J7639,HCPCS,5024210040,NDC,436,EAPG,,outpatient,facility,2.5,UN,428.6,428.6,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPTIFIBATIDE INJ 20 MG,2500005382,CDM,636,RC,J1327,HCPCS,7043602680,NDC,,,,inpatient,facility,10,GR,502.39,502.39,40.19,502.39,,,,,,,,,,,,,,502.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,502.39,,,percent of total billed charges,,,,,,,,,502.39,,,percent of total billed charges,,,256.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,427.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.43,,,percent of total billed charges,,,,,,,,,,,,,,,502.39,,,percent of total billed charges,,,427.03,,,percent of total billed charges,,,,,,,,,,,,,,,502.39,,,percent of total billed charges,,,266.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,502.39,,,percent of total billed charges,,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,,502.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,502.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.01,,,percent of total billed charges,,
EPTIFIBATIDE INJ 20 MG,2500005382,CDM,636,RC,J1327,HCPCS,7043602680,NDC,,,,outpatient,facility,10,GR,502.39,502.39,3.02,548.68,,356.24,,,percent of total billed charges,,,122.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,502.39,,,percent of total billed charges,,,17.57,,,fee schedule,,,16.63,,,fee schedule,,,,,,,,,16.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,502.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,183.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,502.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,502.39,,,fee schedule,,,502.39,,,percent of total billed charges,,,,,,,,,502.39,,,percent of total billed charges,,,307.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.95,,,percent of total billed charges,,,,,,,,,,,,,,,17.72,,,fee schedule,,,17.72,,,fee schedule,,,17.72,,,fee schedule,,,,,,,,,296.41,,,percent of total billed charges,,,548.68,,,per diem,,,502.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,502.39,,,percent of total billed charges,,,427.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.82,,,percent of total billed charges,,,502.39,,,percent of total billed charges,,,502.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,338.91,,,percent of total billed charges,,,406.53,,,percent of total billed charges,,,,,,,,,,,,,,,200.96,,,percent of total billed charges,,,,,,,,,10.88,,,fee schedule,,,7.83,,,fee schedule,,,,,,,,,502.39,,,percent of total billed charges,,,502.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,502.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.19,,,percent of total billed charges,,,502.39,,,percent of total billed charges,,,,,,,,,,,,,,,502.39,,,percent of total billed charges,,,502.39,,,percent of total billed charges,,,,,,,,,4.65,,,fee schedule,,,,,,,,,,,,,,,4.04,,,fee schedule,,,5.38,,,fee schedule,,,3.02,,,fee schedule,,,26.82,,,fee schedule,,,502.39,,,percent of total billed charges,,,502.39,,,percent of total billed charges,,,502.39,,,percent of total billed charges,,,,,,,,,352.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,251.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,296.01,,,percent of total billed charges,,
EPTIFIBATIDE INJ 20 MG,2500005382,CDM,636,RC,J1327,HCPCS,7043602680,NDC,999,EAPG,,outpatient,facility,10,GR,502.39,502.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPTIFIBATIDE INJ 75 MG,2500005384,CDM,636,RC,J1327,HCPCS,7043602780,NDC,,,,inpatient,facility,100,UN,1188,1188,95.04,1188,,,,,,,,,,,,,,1188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1188,,,percent of total billed charges,,,,,,,,,1188,,,percent of total billed charges,,,606.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1011.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,712.8,,,percent of total billed charges,,,,,,,,,,,,,,,1188,,,percent of total billed charges,,,1009.8,,,percent of total billed charges,,,,,,,,,,,,,,,1188,,,percent of total billed charges,,,630.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,475.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1188,,,percent of total billed charges,,,,,,,,,,,,,,,95.04,,,percent of total billed charges,,,1188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,699.97,,,percent of total billed charges,,
EPTIFIBATIDE INJ 75 MG,2500005384,CDM,636,RC,J1327,HCPCS,7043602780,NDC,,,,outpatient,facility,100,UN,1188,1188,3.02,1188,,842.41,,,percent of total billed charges,,,289.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1188,,,percent of total billed charges,,,17.57,,,fee schedule,,,16.63,,,fee schedule,,,,,,,,,16.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,434.81,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1188,,,fee schedule,,,1188,,,percent of total billed charges,,,,,,,,,1188,,,percent of total billed charges,,,728.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,846.45,,,percent of total billed charges,,,,,,,,,,,,,,,17.72,,,fee schedule,,,17.72,,,fee schedule,,,17.72,,,fee schedule,,,,,,,,,700.92,,,percent of total billed charges,,,548.68,,,per diem,,,1188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1188,,,percent of total billed charges,,,1009.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,630.95,,,percent of total billed charges,,,1188,,,percent of total billed charges,,,1188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,801.42,,,percent of total billed charges,,,961.33,,,percent of total billed charges,,,,,,,,,,,,,,,475.2,,,percent of total billed charges,,,,,,,,,10.88,,,fee schedule,,,7.83,,,fee schedule,,,,,,,,,1188,,,percent of total billed charges,,,1188,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1188,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,95.04,,,percent of total billed charges,,,1188,,,percent of total billed charges,,,,,,,,,,,,,,,1188,,,percent of total billed charges,,,1188,,,percent of total billed charges,,,,,,,,,4.65,,,fee schedule,,,,,,,,,,,,,,,4.04,,,fee schedule,,,5.38,,,fee schedule,,,3.02,,,fee schedule,,,26.82,,,fee schedule,,,1188,,,percent of total billed charges,,,1188,,,percent of total billed charges,,,1188,,,percent of total billed charges,,,,,,,,,832.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,594,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,699.97,,,percent of total billed charges,,
EPTIFIBATIDE INJ 75 MG,2500005384,CDM,636,RC,J1327,HCPCS,7043602780,NDC,999,EAPG,,outpatient,facility,100,UN,1188,1188,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PERPHENAZINE 4 MG ORAL,2500005390,CDM,636,RC,Q0175,HCPCS,904660061,NDC,,,,inpatient,facility,4,UN,4.91,4.91,0.39,4.91,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,4.91,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,4.17,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,
PERPHENAZINE 4 MG ORAL,2500005390,CDM,636,RC,Q0175,HCPCS,904660061,NDC,,,,outpatient,facility,4,UN,4.91,4.91,0.39,548.68,,3.48,,,percent of total billed charges,,,1.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.91,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.8,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.91,,,fee schedule,,,4.91,,,percent of total billed charges,,,,,,,,,4.91,,,percent of total billed charges,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,2.9,,,percent of total billed charges,,,548.68,,,per diem,,,4.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.91,,,percent of total billed charges,,,4.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,,3.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,4.91,,,percent of total billed charges,,,4.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.39,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.89,,,percent of total billed charges,,
PERPHENAZINE 4 MG ORAL,2500005390,CDM,636,RC,Q0175,HCPCS,904660061,NDC,999,EAPG,,outpatient,facility,4,UN,4.91,4.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PERPHENAZINE 2 MG TAB,2500005391,CDM,637,RC,Q0175,HCPCS,5253616201,NDC,,,,inpatient,facility,2,UN,5.78,5.78,0.46,5.78,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,5.78,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.41,,,percent of total billed charges,,
PERPHENAZINE 2 MG TAB,2500005391,CDM,637,RC,Q0175,HCPCS,5253616201,NDC,,,,outpatient,facility,2,UN,5.78,5.78,0.46,548.68,,4.1,,,percent of total billed charges,,,1.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.78,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.12,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.78,,,fee schedule,,,5.78,,,percent of total billed charges,,,,,,,,,5.78,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,3.41,,,percent of total billed charges,,,548.68,,,per diem,,,5.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.78,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5.78,,,percent of total billed charges,,,5.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,4.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.41,,,percent of total billed charges,,
PERPHENAZINE 2 MG TAB,2500005391,CDM,637,RC,Q0175,HCPCS,5253616201,NDC,999,EAPG,,outpatient,facility,2,UN,5.78,5.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FOMEPIZOLE 1500 MG INJ,2500005432,CDM,636,RC,J1451,HCPCS,517071001,NDC,,,,inpatient,facility,1.5,ML,5714.31,5714.31,457.14,5714.31,,,,,,,,,,,,,,5714.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5714.31,,,percent of total billed charges,,,,,,,,,5714.31,,,percent of total billed charges,,,2917.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4866.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3428.59,,,percent of total billed charges,,,,,,,,,,,,,,,5714.31,,,percent of total billed charges,,,4857.16,,,percent of total billed charges,,,,,,,,,,,,,,,5714.31,,,percent of total billed charges,,,3034.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2285.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5714.31,,,percent of total billed charges,,,,,,,,,,,,,,,457.14,,,percent of total billed charges,,,5714.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5714.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3366.87,,,percent of total billed charges,,
FOMEPIZOLE 1500 MG INJ,2500005432,CDM,636,RC,J1451,HCPCS,517071001,NDC,,,,outpatient,facility,1.5,ML,5714.31,5714.31,4.79,5714.31,,4052.02,,,percent of total billed charges,,,,,,,,,5714.31,,,percent of total billed charges,,,18.69,,,fee schedule,,,17.68,,,fee schedule,,,,,,,,,17.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,5714.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5714.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5714.31,,,fee schedule,,,5714.31,,,percent of total billed charges,,,,,,,,,5714.31,,,percent of total billed charges,,,3502.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4071.45,,,percent of total billed charges,,,,,,,,,,,,,,,15.3,,,fee schedule,,,15.3,,,fee schedule,,,15.3,,,fee schedule,,,,,,,,,3371.44,,,percent of total billed charges,,,548.68,,,per diem,,,5714.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5714.31,,,percent of total billed charges,,,4857.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3034.87,,,percent of total billed charges,,,5714.31,,,percent of total billed charges,,,5714.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3854.87,,,percent of total billed charges,,,4624.02,,,percent of total billed charges,,,,,,,,,,,,,,,2285.72,,,percent of total billed charges,,,,,,,,,17.25,,,fee schedule,,,12.41,,,fee schedule,,,,,,,,,5714.31,,,percent of total billed charges,,,,,,,,,,,,,,,457.14,,,percent of total billed charges,,,5714.31,,,percent of total billed charges,,,,,,,,,,,,,,,5714.31,,,percent of total billed charges,,,5714.31,,,percent of total billed charges,,,,,,,,,7.37,,,fee schedule,,,,,,,,,,,,,,,6.39,,,fee schedule,,,8.52,,,fee schedule,,,4.79,,,fee schedule,,,8.94,,,fee schedule,,,5714.31,,,percent of total billed charges,,,5714.31,,,percent of total billed charges,,,5714.31,,,percent of total billed charges,,,,,,,,,4006.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2857.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3366.87,,,percent of total billed charges,,
FOMEPIZOLE 1500 MG INJ,2500005432,CDM,636,RC,J1451,HCPCS,517071001,NDC,1689,APC,,outpatient,facility,1.5,ML,5714.31,5714.31,5.91,2091.44,,,,,,,,6.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.22,,,fee schedule,,,,,,,,,2091.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,6.16,,,fee schedule,,,,,,,,,,,,,,,6.47,,,fee schedule,,,6.47,,,fee schedule,,,,,,,,,6.16,,,fee schedule,,,6.16,,,fee schedule,,,6.47,,,fee schedule,,,,,,,,,,,,,,,9.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,6.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.91,,,fee schedule,,,6.59,,,fee schedule,,,6.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.16,,,fee schedule,,,6.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,6.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,6.16,,,fee schedule,,,,,,,,,7.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,6.16,,,fee schedule,,,6.16,,,fee schedule,,,,,,,,,,,,,,,6.16,,,fee schedule,,,,,,,,,6.16,,,fee schedule,,,6.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.16,,,fee schedule,,,,,,,,,,,,,,,6.41,,,fee schedule,,,6.16,,,fee schedule,,,,,,,,,6.16,,,fee schedule,,,,,,,,,6.16,,,fee schedule,,,6.47,,,fee schedule,,,,,,,,
FOMEPIZOLE 1500 MG INJ,2500005432,CDM,636,RC,J1451,HCPCS,517071001,NDC,999,EAPG,,outpatient,facility,1.5,ML,5714.31,5714.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCTREOTIDE DEPOT IM INJ 20 MG,2500005684,CDM,636,RC,J2353,HCPCS,78081881,NDC,,,,inpatient,facility,20,UN,15233.79,15233.79,1218.7,15233.79,,,,,,,,,,,,,,15233.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15233.79,,,percent of total billed charges,,,,,,,,,15233.79,,,percent of total billed charges,,,7778.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12974.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9140.27,,,percent of total billed charges,,,,,,,,,,,,,,,15233.79,,,percent of total billed charges,,,12948.72,,,percent of total billed charges,,,,,,,,,,,,,,,15233.79,,,percent of total billed charges,,,8090.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6093.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,15233.79,,,percent of total billed charges,,,,,,,,,,,,,,,1218.7,,,percent of total billed charges,,,15233.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15233.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8975.75,,,percent of total billed charges,,
OCTREOTIDE DEPOT IM INJ 20 MG,2500005684,CDM,636,RC,J2353,HCPCS,78081881,NDC,,,,outpatient,facility,20,UN,15233.79,15233.79,141.25,15233.79,,10802.28,,,percent of total billed charges,,,,,,,,,15233.79,,,percent of total billed charges,,,279.69,,,fee schedule,,,264.61,,,fee schedule,,,,,,,,,264.61,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,15233.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,15233.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,15233.79,,,fee schedule,,,15233.79,,,percent of total billed charges,,,,,,,,,15233.79,,,percent of total billed charges,,,9336.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10854.08,,,percent of total billed charges,,,,,,,,,,,,,,,210.83,,,fee schedule,,,210.83,,,fee schedule,,,210.83,,,fee schedule,,,,,,,,,8987.94,,,percent of total billed charges,,,548.68,,,per diem,,,15233.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,15233.79,,,percent of total billed charges,,,12948.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8090.67,,,percent of total billed charges,,,15233.79,,,percent of total billed charges,,,15233.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10276.71,,,percent of total billed charges,,,12327.18,,,percent of total billed charges,,,,,,,,,,,,,,,6093.52,,,percent of total billed charges,,,,,,,,,508.5,,,fee schedule,,,365.91,,,fee schedule,,,,,,,,,15233.79,,,percent of total billed charges,,,,,,,,,,,,,,,1218.7,,,percent of total billed charges,,,15233.79,,,percent of total billed charges,,,,,,,,,,,,,,,15233.79,,,percent of total billed charges,,,15233.79,,,percent of total billed charges,,,,,,,,,217.31,,,fee schedule,,,,,,,,,,,,,,,188.35,,,fee schedule,,,251.13,,,fee schedule,,,141.25,,,fee schedule,,,223.62,,,fee schedule,,,15233.79,,,percent of total billed charges,,,15233.79,,,percent of total billed charges,,,15233.79,,,percent of total billed charges,,,,,,,,,10680.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7616.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8975.75,,,percent of total billed charges,,
OCTREOTIDE DEPOT IM INJ 20 MG,2500005684,CDM,636,RC,J2353,HCPCS,78081881,NDC,1207,APC,,outpatient,facility,20,UN,15233.79,15233.79,209.64,5575.57,,,,,,,,224.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,218.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.55,,,fee schedule,,,,,,,,,5575.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,218.37,,,fee schedule,,,,,,,,,,,,,,,229.29,,,fee schedule,,,229.29,,,fee schedule,,,,,,,,,218.37,,,fee schedule,,,218.37,,,fee schedule,,,229.29,,,fee schedule,,,,,,,,,,,,,,,327.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,218.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.64,,,fee schedule,,,233.66,,,fee schedule,,,229.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.37,,,fee schedule,,,218.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,227.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,218.37,,,fee schedule,,,,,,,,,272.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,272.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,218.37,,,fee schedule,,,218.37,,,fee schedule,,,,,,,,,,,,,,,218.37,,,fee schedule,,,,,,,,,218.37,,,fee schedule,,,224.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.37,,,fee schedule,,,,,,,,,,,,,,,227.1,,,fee schedule,,,218.37,,,fee schedule,,,,,,,,,218.37,,,fee schedule,,,,,,,,,218.37,,,fee schedule,,,229.29,,,fee schedule,,,,,,,,
OCTREOTIDE DEPOT IM INJ 20 MG,2500005684,CDM,636,RC,J2353,HCPCS,78081881,NDC,463,EAPG,,outpatient,facility,20,UN,15233.79,15233.79,7053.67,10651.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10651.04,,,fee schedule,,,7053.67,,,fee schedule,,,9468.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCTREOTIDE DEPOT IM INJ 30 MG,2500005685,CDM,636,RC,J2353,HCPCS,78082581,NDC,,,,inpatient,facility,30,UN,22811.45,22811.45,1824.92,22811.45,,,,,,,,,,,,,,22811.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22811.45,,,percent of total billed charges,,,,,,,,,22811.45,,,percent of total billed charges,,,11647.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19428.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13686.87,,,percent of total billed charges,,,,,,,,,,,,,,,22811.45,,,percent of total billed charges,,,19389.73,,,percent of total billed charges,,,,,,,,,,,,,,,22811.45,,,percent of total billed charges,,,12115.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9124.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,22811.45,,,percent of total billed charges,,,,,,,,,,,,,,,1824.92,,,percent of total billed charges,,,22811.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22811.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13440.51,,,percent of total billed charges,,
OCTREOTIDE DEPOT IM INJ 30 MG,2500005685,CDM,636,RC,J2353,HCPCS,78082581,NDC,,,,outpatient,facility,30,UN,22811.45,22811.45,141.25,22811.45,,16175.6,,,percent of total billed charges,,,,,,,,,22811.45,,,percent of total billed charges,,,279.69,,,fee schedule,,,264.61,,,fee schedule,,,,,,,,,264.61,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,22811.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,22811.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,22811.45,,,fee schedule,,,22811.45,,,percent of total billed charges,,,,,,,,,22811.45,,,percent of total billed charges,,,13981.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16253.16,,,percent of total billed charges,,,,,,,,,,,,,,,210.83,,,fee schedule,,,210.83,,,fee schedule,,,210.83,,,fee schedule,,,,,,,,,13458.76,,,percent of total billed charges,,,548.68,,,per diem,,,22811.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,22811.45,,,percent of total billed charges,,,19389.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12115.16,,,percent of total billed charges,,,22811.45,,,percent of total billed charges,,,22811.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15388.6,,,percent of total billed charges,,,18459.03,,,percent of total billed charges,,,,,,,,,,,,,,,9124.58,,,percent of total billed charges,,,,,,,,,508.5,,,fee schedule,,,365.91,,,fee schedule,,,,,,,,,22811.45,,,percent of total billed charges,,,,,,,,,,,,,,,1824.92,,,percent of total billed charges,,,22811.45,,,percent of total billed charges,,,,,,,,,,,,,,,22811.45,,,percent of total billed charges,,,22811.45,,,percent of total billed charges,,,,,,,,,217.31,,,fee schedule,,,,,,,,,,,,,,,188.35,,,fee schedule,,,251.13,,,fee schedule,,,141.25,,,fee schedule,,,223.62,,,fee schedule,,,22811.45,,,percent of total billed charges,,,22811.45,,,percent of total billed charges,,,22811.45,,,percent of total billed charges,,,,,,,,,15993.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11405.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13440.51,,,percent of total billed charges,,
OCTREOTIDE DEPOT IM INJ 30 MG,2500005685,CDM,636,RC,J2353,HCPCS,78082581,NDC,1207,APC,,outpatient,facility,30,UN,22811.45,22811.45,209.64,8348.99,,,,,,,,224.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,218.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.55,,,fee schedule,,,,,,,,,8348.99,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,218.37,,,fee schedule,,,,,,,,,,,,,,,229.29,,,fee schedule,,,229.29,,,fee schedule,,,,,,,,,218.37,,,fee schedule,,,218.37,,,fee schedule,,,229.29,,,fee schedule,,,,,,,,,,,,,,,327.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,218.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.64,,,fee schedule,,,233.66,,,fee schedule,,,229.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.37,,,fee schedule,,,218.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,227.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,218.37,,,fee schedule,,,,,,,,,272.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,272.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,218.37,,,fee schedule,,,218.37,,,fee schedule,,,,,,,,,,,,,,,218.37,,,fee schedule,,,,,,,,,218.37,,,fee schedule,,,224.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.37,,,fee schedule,,,,,,,,,,,,,,,227.1,,,fee schedule,,,218.37,,,fee schedule,,,,,,,,,218.37,,,fee schedule,,,,,,,,,218.37,,,fee schedule,,,229.29,,,fee schedule,,,,,,,,
OCTREOTIDE DEPOT IM INJ 30 MG,2500005685,CDM,636,RC,J2353,HCPCS,78082581,NDC,463,EAPG,,outpatient,facility,30,UN,22811.45,22811.45,7053.67,10651.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10651.04,,,fee schedule,,,7053.67,,,fee schedule,,,9468.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TENECTEPLACE PER 50 MG INJ,2500005770,CDM,636,RC,J3101,HCPCS,5024212047,NDC,,,,inpatient,facility,10,ML,25831.08,25831.08,2066.49,25831.08,,,,,,,,,,,,,,25831.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25831.08,,,percent of total billed charges,,,,,,,,,25831.08,,,percent of total billed charges,,,13189.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22000.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15498.65,,,percent of total billed charges,,,,,,,,,,,,,,,25831.08,,,percent of total billed charges,,,21956.42,,,percent of total billed charges,,,,,,,,,,,,,,,25831.08,,,percent of total billed charges,,,13718.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10332.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,25831.08,,,percent of total billed charges,,,,,,,,,,,,,,,2066.49,,,percent of total billed charges,,,25831.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25831.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15219.67,,,percent of total billed charges,,
TENECTEPLACE PER 50 MG INJ,2500005770,CDM,636,RC,J3101,HCPCS,5024212047,NDC,,,,outpatient,facility,10,ML,25831.08,25831.08,98.19,25831.08,,18316.82,,,percent of total billed charges,,,,,,,,,25831.08,,,percent of total billed charges,,,204.4,,,fee schedule,,,193.37,,,fee schedule,,,,,,,,,193.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,25831.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,25831.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,25831.08,,,fee schedule,,,25831.08,,,percent of total billed charges,,,,,,,,,25831.08,,,percent of total billed charges,,,15831.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18404.64,,,percent of total billed charges,,,,,,,,,,,,,,,153.11,,,fee schedule,,,153.11,,,fee schedule,,,153.11,,,fee schedule,,,,,,,,,15240.34,,,percent of total billed charges,,,548.68,,,per diem,,,25831.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,25831.08,,,percent of total billed charges,,,21956.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13718.89,,,percent of total billed charges,,,25831.08,,,percent of total billed charges,,,25831.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17425.65,,,percent of total billed charges,,,20902.51,,,percent of total billed charges,,,,,,,,,,,,,,,10332.43,,,percent of total billed charges,,,,,,,,,353.49,,,fee schedule,,,254.36,,,fee schedule,,,,,,,,,25831.08,,,percent of total billed charges,,,,,,,,,,,,,,,2066.49,,,percent of total billed charges,,,25831.08,,,percent of total billed charges,,,,,,,,,,,,,,,25831.08,,,percent of total billed charges,,,25831.08,,,percent of total billed charges,,,,,,,,,151.06,,,fee schedule,,,,,,,,,,,,,,,130.93,,,fee schedule,,,174.57,,,fee schedule,,,98.19,,,fee schedule,,,163.41,,,fee schedule,,,25831.08,,,percent of total billed charges,,,25831.08,,,percent of total billed charges,,,25831.08,,,percent of total billed charges,,,,,,,,,18110.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12915.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15219.67,,,percent of total billed charges,,
TENECTEPLACE PER 50 MG INJ,2500005770,CDM,636,RC,J3101,HCPCS,5024212047,NDC,9002,APC,,outpatient,facility,10,ML,25831.08,25831.08,155.93,9454.18,,,,,,,,167.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,162.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.05,,,fee schedule,,,,,,,,,9454.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,162.43,,,fee schedule,,,,,,,,,,,,,,,170.55,,,fee schedule,,,170.55,,,fee schedule,,,,,,,,,162.43,,,fee schedule,,,162.43,,,fee schedule,,,170.55,,,fee schedule,,,,,,,,,,,,,,,243.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,162.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.93,,,fee schedule,,,173.8,,,fee schedule,,,170.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.43,,,fee schedule,,,162.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,168.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,162.43,,,fee schedule,,,,,,,,,203.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,203.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,162.43,,,fee schedule,,,162.43,,,fee schedule,,,,,,,,,,,,,,,162.43,,,fee schedule,,,,,,,,,162.43,,,fee schedule,,,167.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.43,,,fee schedule,,,,,,,,,,,,,,,168.93,,,fee schedule,,,162.43,,,fee schedule,,,,,,,,,162.43,,,fee schedule,,,,,,,,,162.43,,,fee schedule,,,170.55,,,fee schedule,,,,,,,,
TENECTEPLACE PER 50 MG INJ,2500005770,CDM,636,RC,J3101,HCPCS,5024212047,NDC,999,EAPG,,outpatient,facility,10,ML,25831.08,25831.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE LIPOSOM 266MG/20ML,2500005783,CDM,636,RC,C9290,HCPCS,6525026609,NDC,,,,inpatient,facility,20,UN,1039.5,1039.5,83.16,1039.5,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,,,,,1039.5,,,percent of total billed charges,,,530.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,885.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,623.7,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,883.58,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,552.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,415.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,,,,,,,,,,,83.16,,,percent of total billed charges,,,1039.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.47,,,percent of total billed charges,,
BUPIVACAINE LIPOSOM 266MG/20ML,2500005783,CDM,636,RC,C9290,HCPCS,6525026609,NDC,,,,outpatient,facility,20,UN,1039.5,1039.5,83.16,1039.5,,737.11,,,percent of total billed charges,,,253.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1039.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,380.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1039.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1039.5,,,fee schedule,,,1039.5,,,percent of total billed charges,,,,,,,,,1039.5,,,percent of total billed charges,,,637.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,740.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,613.3,,,percent of total billed charges,,,548.68,,,per diem,,,1039.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1039.5,,,percent of total billed charges,,,883.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.08,,,percent of total billed charges,,,1039.5,,,percent of total billed charges,,,1039.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,701.25,,,percent of total billed charges,,,841.16,,,percent of total billed charges,,,,,,,,,,,,,,,415.8,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1039.5,,,percent of total billed charges,,,1039.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1039.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,83.16,,,percent of total billed charges,,,1039.5,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,1039.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,779.63,,,percent of total billed charges,,,1039.5,,,percent of total billed charges,,,1039.5,,,percent of total billed charges,,,1039.5,,,percent of total billed charges,,,,,,,,,728.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,519.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,612.47,,,percent of total billed charges,,
BUPIVACAINE LIPOSOM 266MG/20ML,2500005783,CDM,636,RC,C9290,HCPCS,6525026609,NDC,999,EAPG,,outpatient,facility,20,UN,1039.5,1039.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALTEPLASE RECOMB IV 2 MG,2500005891,CDM,636,RC,J2997,HCPCS,5024204164,NDC,,,,inpatient,facility,2,GR,581.96,581.96,46.56,581.96,,,,,,,,,,,,,,581.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,581.96,,,percent of total billed charges,,,,,,,,,581.96,,,percent of total billed charges,,,297.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,495.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.18,,,percent of total billed charges,,,,,,,,,,,,,,,581.96,,,percent of total billed charges,,,494.67,,,percent of total billed charges,,,,,,,,,,,,,,,581.96,,,percent of total billed charges,,,309.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,581.96,,,percent of total billed charges,,,,,,,,,,,,,,,46.56,,,percent of total billed charges,,,581.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,581.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,342.89,,,percent of total billed charges,,
ALTEPLASE RECOMB IV 2 MG,2500005891,CDM,636,RC,J2997,HCPCS,5024204164,NDC,,,,outpatient,facility,2,GR,581.96,581.96,46.56,581.96,,412.67,,,percent of total billed charges,,,,,,,,,581.96,,,percent of total billed charges,,,118.56,,,fee schedule,,,112.17,,,fee schedule,,,,,,,,,112.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,581.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,581.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,581.96,,,fee schedule,,,581.96,,,percent of total billed charges,,,,,,,,,581.96,,,percent of total billed charges,,,356.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,414.65,,,percent of total billed charges,,,,,,,,,,,,,,,88.97,,,fee schedule,,,88.97,,,fee schedule,,,88.97,,,fee schedule,,,,,,,,,343.36,,,percent of total billed charges,,,548.68,,,per diem,,,581.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,581.96,,,percent of total billed charges,,,494.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,309.08,,,percent of total billed charges,,,581.96,,,percent of total billed charges,,,581.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.59,,,percent of total billed charges,,,470.92,,,percent of total billed charges,,,,,,,,,,,,,,,232.78,,,percent of total billed charges,,,,,,,,,216.29,,,fee schedule,,,155.64,,,fee schedule,,,,,,,,,581.96,,,percent of total billed charges,,,,,,,,,,,,,,,46.56,,,percent of total billed charges,,,581.96,,,percent of total billed charges,,,,,,,,,,,,,,,581.96,,,percent of total billed charges,,,581.96,,,percent of total billed charges,,,,,,,,,92.43,,,fee schedule,,,,,,,,,,,,,,,80.12,,,fee schedule,,,106.82,,,fee schedule,,,60.08,,,fee schedule,,,94.79,,,fee schedule,,,581.96,,,percent of total billed charges,,,581.96,,,percent of total billed charges,,,581.96,,,percent of total billed charges,,,,,,,,,408.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,342.89,,,percent of total billed charges,,
ALTEPLASE RECOMB IV 2 MG,2500005891,CDM,636,RC,J2997,HCPCS,5024204164,NDC,7048,APC,,outpatient,facility,2,GR,581.96,581.96,87.82,213,,,,,,,,94.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.39,,,fee schedule,,,,,,,,,213,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,96.05,,,fee schedule,,,96.05,,,fee schedule,,,,,,,,,91.48,,,fee schedule,,,91.48,,,fee schedule,,,96.05,,,fee schedule,,,,,,,,,,,,,,,137.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.82,,,fee schedule,,,97.88,,,fee schedule,,,96.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,91.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,95.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,114.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,114.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,91.48,,,fee schedule,,,91.48,,,fee schedule,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,91.48,,,fee schedule,,,94.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,95.14,,,fee schedule,,,91.48,,,fee schedule,,,,,,,,,91.48,,,fee schedule,,,,,,,,,91.48,,,fee schedule,,,96.05,,,fee schedule,,,,,,,,
ALTEPLASE RECOMB IV 2 MG,2500005891,CDM,636,RC,J2997,HCPCS,5024204164,NDC,436,EAPG,,outpatient,facility,2,GR,581.96,581.96,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALTEPLASE RECOMB IV 50 MG,2500005897,CDM,636,RC,J2997,HCPCS,5024204413,NDC,,,,inpatient,facility,50,GR,14520.59,14520.59,1161.65,14520.59,,,,,,,,,,,,,,14520.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14520.59,,,percent of total billed charges,,,,,,,,,14520.59,,,percent of total billed charges,,,7414.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12367.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8712.35,,,percent of total billed charges,,,,,,,,,,,,,,,14520.59,,,percent of total billed charges,,,12342.5,,,percent of total billed charges,,,,,,,,,,,,,,,14520.59,,,percent of total billed charges,,,7711.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5808.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14520.59,,,percent of total billed charges,,,,,,,,,,,,,,,1161.65,,,percent of total billed charges,,,14520.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14520.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8555.53,,,percent of total billed charges,,
ALTEPLASE RECOMB IV 50 MG,2500005897,CDM,636,RC,J2997,HCPCS,5024204413,NDC,,,,outpatient,facility,50,GR,14520.59,14520.59,60.08,14520.59,,10296.55,,,percent of total billed charges,,,,,,,,,14520.59,,,percent of total billed charges,,,118.56,,,fee schedule,,,112.17,,,fee schedule,,,,,,,,,112.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,14520.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14520.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14520.59,,,fee schedule,,,14520.59,,,percent of total billed charges,,,,,,,,,14520.59,,,percent of total billed charges,,,8899.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10345.92,,,percent of total billed charges,,,,,,,,,,,,,,,88.97,,,fee schedule,,,88.97,,,fee schedule,,,88.97,,,fee schedule,,,,,,,,,8567.15,,,percent of total billed charges,,,548.68,,,per diem,,,14520.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14520.59,,,percent of total billed charges,,,12342.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7711.89,,,percent of total billed charges,,,14520.59,,,percent of total billed charges,,,14520.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9795.59,,,percent of total billed charges,,,11750.06,,,percent of total billed charges,,,,,,,,,,,,,,,5808.24,,,percent of total billed charges,,,,,,,,,216.29,,,fee schedule,,,155.64,,,fee schedule,,,,,,,,,14520.59,,,percent of total billed charges,,,,,,,,,,,,,,,1161.65,,,percent of total billed charges,,,14520.59,,,percent of total billed charges,,,,,,,,,,,,,,,14520.59,,,percent of total billed charges,,,14520.59,,,percent of total billed charges,,,,,,,,,92.43,,,fee schedule,,,,,,,,,,,,,,,80.12,,,fee schedule,,,106.82,,,fee schedule,,,60.08,,,fee schedule,,,94.79,,,fee schedule,,,14520.59,,,percent of total billed charges,,,14520.59,,,percent of total billed charges,,,14520.59,,,percent of total billed charges,,,,,,,,,10180.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7260.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8555.53,,,percent of total billed charges,,
ALTEPLASE RECOMB IV 50 MG,2500005897,CDM,636,RC,J2997,HCPCS,5024204413,NDC,7048,APC,,outpatient,facility,50,GR,14520.59,14520.59,87.82,5314.54,,,,,,,,94.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.39,,,fee schedule,,,,,,,,,5314.54,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,96.05,,,fee schedule,,,96.05,,,fee schedule,,,,,,,,,91.48,,,fee schedule,,,91.48,,,fee schedule,,,96.05,,,fee schedule,,,,,,,,,,,,,,,137.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.82,,,fee schedule,,,97.88,,,fee schedule,,,96.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,91.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,95.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,114.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,114.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,91.48,,,fee schedule,,,91.48,,,fee schedule,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,91.48,,,fee schedule,,,94.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.48,,,fee schedule,,,,,,,,,,,,,,,95.14,,,fee schedule,,,91.48,,,fee schedule,,,,,,,,,91.48,,,fee schedule,,,,,,,,,91.48,,,fee schedule,,,96.05,,,fee schedule,,,,,,,,
ALTEPLASE RECOMB IV 50 MG,2500005897,CDM,636,RC,J2997,HCPCS,5024204413,NDC,436,EAPG,,outpatient,facility,50,GR,14520.59,14520.59,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMIODARONE HCL IV 150 MG,2500005905,CDM,636,RC,J0282,HCPCS,4306615010,NDC,,,,inpatient,facility,100,UN,114.48,114.48,9.16,114.48,,,,,,,,,,,,,,114.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.48,,,percent of total billed charges,,,,,,,,,114.48,,,percent of total billed charges,,,58.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.69,,,percent of total billed charges,,,,,,,,,,,,,,,114.48,,,percent of total billed charges,,,97.31,,,percent of total billed charges,,,,,,,,,,,,,,,114.48,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,114.48,,,percent of total billed charges,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,114.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.45,,,percent of total billed charges,,
AMIODARONE HCL IV 150 MG,2500005905,CDM,636,RC,J0282,HCPCS,4306615010,NDC,,,,outpatient,facility,100,UN,114.48,114.48,0.85,548.68,,81.18,,,percent of total billed charges,,,27.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,114.48,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,114.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,41.9,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,114.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,114.48,,,fee schedule,,,114.48,,,percent of total billed charges,,,,,,,,,114.48,,,percent of total billed charges,,,70.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,67.54,,,percent of total billed charges,,,548.68,,,per diem,,,114.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,114.48,,,percent of total billed charges,,,97.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.8,,,percent of total billed charges,,,114.48,,,percent of total billed charges,,,114.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.23,,,percent of total billed charges,,,92.64,,,percent of total billed charges,,,,,,,,,,,,,,,45.79,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,114.48,,,percent of total billed charges,,,114.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,114.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.16,,,percent of total billed charges,,,114.48,,,percent of total billed charges,,,,,,,,,,,,,,,114.48,,,percent of total billed charges,,,114.48,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,114.48,,,percent of total billed charges,,,114.48,,,percent of total billed charges,,,114.48,,,percent of total billed charges,,,,,,,,,80.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,67.45,,,percent of total billed charges,,
AMIODARONE HCL IV 150 MG,2500005905,CDM,636,RC,J0282,HCPCS,4306615010,NDC,435,EAPG,,outpatient,facility,100,UN,114.48,114.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROPIVACAINE HCL 100 MG,2500006014,CDM,636,RC,J2795,HCPCS,6332328810,NDC,,,,inpatient,facility,10,UN,47.78,47.78,3.82,47.78,,,,,,,,,,,,,,47.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.78,,,percent of total billed charges,,,,,,,,,47.78,,,percent of total billed charges,,,24.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.67,,,percent of total billed charges,,,,,,,,,,,,,,,47.78,,,percent of total billed charges,,,40.61,,,percent of total billed charges,,,,,,,,,,,,,,,47.78,,,percent of total billed charges,,,25.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,47.78,,,percent of total billed charges,,,,,,,,,,,,,,,3.82,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.15,,,percent of total billed charges,,
ROPIVACAINE HCL 100 MG,2500006014,CDM,636,RC,J2795,HCPCS,6332328810,NDC,,,,outpatient,facility,10,UN,47.78,47.78,0.08,548.68,,33.88,,,percent of total billed charges,,,11.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,47.78,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,47.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,17.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,47.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,47.78,,,fee schedule,,,47.78,,,percent of total billed charges,,,,,,,,,47.78,,,percent of total billed charges,,,29.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,28.19,,,percent of total billed charges,,,548.68,,,per diem,,,47.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,47.78,,,percent of total billed charges,,,40.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.38,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.23,,,percent of total billed charges,,,38.66,,,percent of total billed charges,,,,,,,,,,,,,,,19.11,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,47.78,,,percent of total billed charges,,,47.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,47.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.82,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,,,,,,,,,,,,,47.78,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.08,,,fee schedule,,,47.78,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,,,,,,,33.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,28.15,,,percent of total billed charges,,
ROPIVACAINE HCL 100 MG,2500006014,CDM,636,RC,J2795,HCPCS,6332328810,NDC,496,EAPG,,outpatient,facility,10,UN,47.78,47.78,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BOTULINUM TOXIN B 2500 U,2500006072,CDM,636,RC,J0587,HCPCS,1045471010,NDC,,,,inpatient,facility,0.5,UN,1027.32,1027.32,82.19,1027.32,,,,,,,,,,,,,,1027.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.32,,,percent of total billed charges,,,,,,,,,1027.32,,,percent of total billed charges,,,524.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,874.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,616.39,,,percent of total billed charges,,,,,,,,,,,,,,,1027.32,,,percent of total billed charges,,,873.22,,,percent of total billed charges,,,,,,,,,,,,,,,1027.32,,,percent of total billed charges,,,545.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.32,,,percent of total billed charges,,,,,,,,,,,,,,,82.19,,,percent of total billed charges,,,1027.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1027.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,605.3,,,percent of total billed charges,,
BOTULINUM TOXIN B 2500 U,2500006072,CDM,636,RC,J0587,HCPCS,1045471010,NDC,,,,outpatient,facility,0.5,UN,1027.32,1027.32,8.51,1027.32,,728.47,,,percent of total billed charges,,,,,,,,,1027.32,,,percent of total billed charges,,,16.95,,,fee schedule,,,16.04,,,fee schedule,,,,,,,,,16.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12.26,,,fee schedule,,,1027.32,,,fee schedule,,,1027.32,,,percent of total billed charges,,,,,,,,,1027.32,,,percent of total billed charges,,,629.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,731.97,,,percent of total billed charges,,,,,,,,,,,,,,,12.36,,,fee schedule,,,12.36,,,fee schedule,,,12.36,,,fee schedule,,,,,,,,,606.12,,,percent of total billed charges,,,548.68,,,per diem,,,1027.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1027.32,,,percent of total billed charges,,,873.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,545.61,,,percent of total billed charges,,,1027.32,,,percent of total billed charges,,,1027.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,693.03,,,percent of total billed charges,,,831.31,,,percent of total billed charges,,,,,,,,,,,,,,,410.93,,,percent of total billed charges,,,,,,,,,30.64,,,fee schedule,,,22.05,,,fee schedule,,,,,,,,,1027.32,,,percent of total billed charges,,,,,,,,,,,,,,,82.19,,,percent of total billed charges,,,1027.32,,,percent of total billed charges,,,,,,,,,,,,,,,1027.32,,,percent of total billed charges,,,1027.32,,,percent of total billed charges,,,,,,,,,13.09,,,fee schedule,,,,,,,,,,,,,,,11.35,,,fee schedule,,,15.13,,,fee schedule,,,8.51,,,fee schedule,,,13.55,,,fee schedule,,,1027.32,,,percent of total billed charges,,,1027.32,,,percent of total billed charges,,,1027.32,,,percent of total billed charges,,,,,,,,,720.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,513.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,605.3,,,percent of total billed charges,,
BOTULINUM TOXIN B 2500 U,2500006072,CDM,636,RC,J0587,HCPCS,1045471010,NDC,9018,APC,,outpatient,facility,0.5,UN,1027.32,1027.32,12.47,376,,,,,,,,13.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,12.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.12,,,fee schedule,,,,,,,,,376,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,12.99,,,fee schedule,,,,,,,,,,,,,,,13.64,,,fee schedule,,,13.64,,,fee schedule,,,,,,,,,12.99,,,fee schedule,,,12.99,,,fee schedule,,,13.64,,,fee schedule,,,,,,,,,,,,,,,19.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,12.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,,fee schedule,,,13.9,,,fee schedule,,,13.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.99,,,fee schedule,,,12.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,13.51,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,12.99,,,fee schedule,,,,,,,,,16.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,12.99,,,fee schedule,,,12.99,,,fee schedule,,,,,,,,,,,,,,,12.99,,,fee schedule,,,,,,,,,12.99,,,fee schedule,,,13.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.99,,,fee schedule,,,,,,,,,,,,,,,13.51,,,fee schedule,,,12.99,,,fee schedule,,,,,,,,,12.99,,,fee schedule,,,,,,,,,12.99,,,fee schedule,,,13.64,,,fee schedule,,,,,,,,
BOTULINUM TOXIN B 2500 U,2500006072,CDM,636,RC,J0587,HCPCS,1045471010,NDC,439,EAPG,,outpatient,facility,0.5,UN,1027.32,1027.32,790.67,1193.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1193.91,,,fee schedule,,,790.67,,,fee schedule,,,1061.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.67,,,fee schedule,,,790.67,,,fee schedule,,,790.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,790.67,,,fee schedule,,,,,,,,,,,,,,,790.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUTEROL/IPRATROP 3ML NEB,2500006081,CDM,637,RC,J7620,HCPCS,487020101,NDC,,,,inpatient,facility,3,UN,7.29,7.29,0.58,7.29,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,,,,,,,7.29,,,percent of total billed charges,,,3.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,6.2,,,percent of total billed charges,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,
ALBUTEROL/IPRATROP 3ML NEB,2500006081,CDM,637,RC,J7620,HCPCS,487020101,NDC,,,,outpatient,facility,3,UN,7.29,7.29,0.09,548.68,,5.17,,,percent of total billed charges,,,1.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.29,,,percent of total billed charges,,,0.25,,,fee schedule,,,0.23,,,fee schedule,,,,,,,,,0.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.67,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.32,,,fee schedule,,,0.19,,,fee schedule,,,7.29,,,percent of total billed charges,,,,,,,,,7.29,,,percent of total billed charges,,,4.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,fee schedule,,,0.17,,,fee schedule,,,0.17,,,fee schedule,,,,,,,,,4.3,,,percent of total billed charges,,,548.68,,,per diem,,,7.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.29,,,percent of total billed charges,,,6.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,5.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,,,,,,,,0.32,,,fee schedule,,,0.23,,,fee schedule,,,,,,,,,7.29,,,percent of total billed charges,,,7.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.58,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,,,,,,,0.14,,,fee schedule,,,,,,,,,,,,,,,0.12,,,fee schedule,,,0.16,,,fee schedule,,,0.09,,,fee schedule,,,0.2,,,fee schedule,,,7.29,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,,,,,,,5.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.65,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.3,,,percent of total billed charges,,
ALBUTEROL/IPRATROP 3ML NEB,2500006081,CDM,637,RC,J7620,HCPCS,487020101,NDC,496,EAPG,,outpatient,facility,3,UN,7.29,7.29,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUTEROL HFA 6.7 GM INHALER,2500006085,CDM,637,RC,6909714260,NDC,,,,,,inpatient,facility,6.7,UN,244.27,244.27,19.54,244.27,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,,,,,,,244.27,,,percent of total billed charges,,,124.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,208.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.56,,,percent of total billed charges,,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,207.63,,,percent of total billed charges,,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,129.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,19.54,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.92,,,percent of total billed charges,,
ALBUTEROL HFA 6.7 GM INHALER,2500006085,CDM,637,RC,6909714260,NDC,,,,,,outpatient,facility,6.7,UN,244.27,244.27,19.54,548.68,,173.21,,,percent of total billed charges,,,59.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,244.27,,,percent of total billed charges,,,153.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,171.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,171.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,89.4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,244.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,244.27,,,fee schedule,,,244.27,,,percent of total billed charges,,,,,,,,,244.27,,,percent of total billed charges,,,149.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.04,,,percent of total billed charges,,,,,,,,,,,,,,,131.91,,,percent of total billed charges,,,127.02,,,percent of total billed charges,,,134.35,,,percent of total billed charges,,,,,,,,,144.12,,,percent of total billed charges,,,548.68,,,per diem,,,244.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,244.27,,,percent of total billed charges,,,207.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,129.73,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.78,,,percent of total billed charges,,,197.66,,,percent of total billed charges,,,,,,,,,,,,,,,97.71,,,percent of total billed charges,,,,,,,,,90.38,,,percent of total billed charges,,,90.38,,,percent of total billed charges,,,,,,,,,244.27,,,percent of total billed charges,,,244.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,244.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.54,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,244.27,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,,,,,,,227.22,,,percent of total billed charges,,,,,,,,,,,,,,,227.22,,,percent of total billed charges,,,227.22,,,percent of total billed charges,,,227.22,,,percent of total billed charges,,,183.2,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,244.27,,,percent of total billed charges,,,,,,,,,171.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,143.92,,,percent of total billed charges,,
ALBUTEROL HFA 6.7 GM INHALER,2500006085,CDM,637,RC,6909714260,NDC,999,EAPG,,,,outpatient,facility,6.7,UN,244.27,244.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUTEROL 8 GM INH,2500006089,CDM,637,RC,173068224,NDC,,,,,,inpatient,facility,1,UN,74.98,74.98,6,74.98,,,,,,,,,,,,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.98,,,percent of total billed charges,,,,,,,,,74.98,,,percent of total billed charges,,,38.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.99,,,percent of total billed charges,,,,,,,,,,,,,,,74.98,,,percent of total billed charges,,,63.73,,,percent of total billed charges,,,,,,,,,,,,,,,74.98,,,percent of total billed charges,,,39.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.18,,,percent of total billed charges,,
ALBUTEROL 8 GM INH,2500006089,CDM,637,RC,173068224,NDC,,,,,,outpatient,facility,1,UN,74.98,74.98,6,548.68,,53.17,,,percent of total billed charges,,,18.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,74.98,,,percent of total billed charges,,,46.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,52.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,52.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,27.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,74.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,74.98,,,fee schedule,,,74.98,,,percent of total billed charges,,,,,,,,,74.98,,,percent of total billed charges,,,45.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.42,,,percent of total billed charges,,,,,,,,,,,,,,,40.49,,,percent of total billed charges,,,38.99,,,percent of total billed charges,,,41.24,,,percent of total billed charges,,,,,,,,,44.24,,,percent of total billed charges,,,548.68,,,per diem,,,74.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,74.98,,,percent of total billed charges,,,63.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.82,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.58,,,percent of total billed charges,,,60.67,,,percent of total billed charges,,,,,,,,,,,,,,,29.99,,,percent of total billed charges,,,,,,,,,27.74,,,percent of total billed charges,,,27.74,,,percent of total billed charges,,,,,,,,,74.98,,,percent of total billed charges,,,74.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,74.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,,,,,,,74.98,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,69.75,,,percent of total billed charges,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,69.75,,,percent of total billed charges,,,69.75,,,percent of total billed charges,,,56.23,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,74.98,,,percent of total billed charges,,,,,,,,,52.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,44.18,,,percent of total billed charges,,
ALBUTEROL 8 GM INH,2500006089,CDM,637,RC,173068224,NDC,999,EAPG,,,,outpatient,facility,1,UN,74.98,74.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACARBOSE 25 MG TAB,2500006322,CDM,637,RC,54014025,NDC,,,,,,inpatient,facility,25,UN,3,3,0.24,3,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,3,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,
ACARBOSE 25 MG TAB,2500006322,CDM,637,RC,54014025,NDC,,,,,,outpatient,facility,25,UN,3,3,0.24,548.68,,2.13,,,percent of total billed charges,,,0.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3,,,percent of total billed charges,,,1.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3,,,fee schedule,,,3,,,percent of total billed charges,,,,,,,,,3,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,1.77,,,percent of total billed charges,,,548.68,,,per diem,,,3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,1.11,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,3,,,percent of total billed charges,,,3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,2.79,,,percent of total billed charges,,,2.79,,,percent of total billed charges,,,2.79,,,percent of total billed charges,,,2.25,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,2.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.77,,,percent of total billed charges,,
ACARBOSE 25 MG TAB,2500006322,CDM,637,RC,54014025,NDC,999,EAPG,,,,outpatient,facility,25,UN,3,3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAMIN/BUTALBITAL/CAFF  TAB,2500006350,CDM,637,RC,904693806,NDC,,,,,,inpatient,facility,1,UN,5.97,5.97,0.48,5.97,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,5.97,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,
ACETAMIN/BUTALBITAL/CAFF  TAB,2500006350,CDM,637,RC,904693806,NDC,,,,,,outpatient,facility,1,UN,5.97,5.97,0.48,548.68,,4.23,,,percent of total billed charges,,,1.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.97,,,percent of total billed charges,,,3.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.19,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.97,,,fee schedule,,,5.97,,,percent of total billed charges,,,,,,,,,5.97,,,percent of total billed charges,,,3.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.25,,,percent of total billed charges,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,3.28,,,percent of total billed charges,,,,,,,,,3.52,,,percent of total billed charges,,,548.68,,,per diem,,,5.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.97,,,percent of total billed charges,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,4.83,,,percent of total billed charges,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,5.97,,,percent of total billed charges,,,5.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.48,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,5.55,,,percent of total billed charges,,,,,,,,,,,,,,,5.55,,,percent of total billed charges,,,5.55,,,percent of total billed charges,,,5.55,,,percent of total billed charges,,,4.48,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.52,,,percent of total billed charges,,
ACETAMIN/BUTALBITAL/CAFF  TAB,2500006350,CDM,637,RC,904693806,NDC,999,EAPG,,,,outpatient,facility,1,UN,5.97,5.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAMINOPHEN 120 MG SUPP,2500006360,CDM,637,RC,4580273230,NDC,,,,,,inpatient,facility,120,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
ACETAMINOPHEN 120 MG SUPP,2500006360,CDM,637,RC,4580273230,NDC,,,,,,outpatient,facility,120,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
ACETAMINOPHEN 120 MG SUPP,2500006360,CDM,637,RC,4580273230,NDC,999,EAPG,,,,outpatient,facility,120,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAMINOPHEN 325 MG SUPP,2500006362,CDM,637,RC,5167221162,NDC,,,,,,inpatient,facility,325,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
ACETAMINOPHEN 325 MG SUPP,2500006362,CDM,637,RC,5167221162,NDC,,,,,,outpatient,facility,325,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
ACETAMINOPHEN 325 MG SUPP,2500006362,CDM,637,RC,5167221162,NDC,999,EAPG,,,,outpatient,facility,325,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAMINOPHEN 325 MG TAB,2500006363,CDM,637,RC,904677361,NDC,,,,,,inpatient,facility,325,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
ACETAMINOPHEN 325 MG TAB,2500006363,CDM,637,RC,904677361,NDC,,,,,,outpatient,facility,325,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
ACETAMINOPHEN 325 MG TAB,2500006363,CDM,637,RC,904677361,NDC,999,EAPG,,,,outpatient,facility,325,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAMINOPHEN 650 MG SUPP,2500006367,CDM,637,RC,4580273030,NDC,,,,,,inpatient,facility,650,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
ACETAMINOPHEN 650 MG SUPP,2500006367,CDM,637,RC,4580273030,NDC,,,,,,outpatient,facility,650,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
ACETAMINOPHEN 650 MG SUPP,2500006367,CDM,637,RC,4580273030,NDC,999,EAPG,,,,outpatient,facility,650,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAMINOPHEN 650 MG/20.3 ML,2500006368,CDM,637,RC,904682076,NDC,,,,,,inpatient,facility,20.3,UN,2.55,2.55,0.2,2.55,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,2.55,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,
ACETAMINOPHEN 650 MG/20.3 ML,2500006368,CDM,637,RC,904682076,NDC,,,,,,outpatient,facility,20.3,UN,2.55,2.55,0.2,548.68,,1.81,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.55,,,percent of total billed charges,,,1.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.93,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.55,,,fee schedule,,,2.55,,,percent of total billed charges,,,,,,,,,2.55,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,,,,,,,1.5,,,percent of total billed charges,,,548.68,,,per diem,,,2.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.55,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,0.94,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,,,,,,,2.55,,,percent of total billed charges,,,2.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.5,,,percent of total billed charges,,
ACETAMINOPHEN 650 MG/20.3 ML,2500006368,CDM,637,RC,904682076,NDC,999,EAPG,,,,outpatient,facility,20.3,UN,2.55,2.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAMINOPHEN IV 1000MG/100ML,2500006376,CDM,636,RC,J0138,HCPCS,781315695,NDC,,,,inpatient,facility,100,UN,146.55,146.55,11.72,146.55,,,,,,,,,,,,,,146.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.55,,,percent of total billed charges,,,,,,,,,146.55,,,percent of total billed charges,,,74.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.93,,,percent of total billed charges,,,,,,,,,,,,,,,146.55,,,percent of total billed charges,,,124.57,,,percent of total billed charges,,,,,,,,,,,,,,,146.55,,,percent of total billed charges,,,77.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,146.55,,,percent of total billed charges,,,,,,,,,,,,,,,11.72,,,percent of total billed charges,,,146.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,146.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.35,,,percent of total billed charges,,
ACETAMINOPHEN IV 1000MG/100ML,2500006376,CDM,636,RC,J0138,HCPCS,781315695,NDC,,,,outpatient,facility,100,UN,146.55,146.55,11.72,548.68,,103.92,,,percent of total billed charges,,,35.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,146.55,,,percent of total billed charges,,,91.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,103.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,103.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,146.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,53.64,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,146.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,146.55,,,fee schedule,,,146.55,,,percent of total billed charges,,,,,,,,,146.55,,,percent of total billed charges,,,89.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.42,,,percent of total billed charges,,,,,,,,,,,,,,,79.14,,,percent of total billed charges,,,76.21,,,percent of total billed charges,,,80.6,,,percent of total billed charges,,,,,,,,,86.46,,,percent of total billed charges,,,548.68,,,per diem,,,146.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,146.55,,,percent of total billed charges,,,124.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.83,,,percent of total billed charges,,,146.55,,,percent of total billed charges,,,146.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.86,,,percent of total billed charges,,,118.59,,,percent of total billed charges,,,,,,,,,,,,,,,58.62,,,percent of total billed charges,,,,,,,,,54.22,,,percent of total billed charges,,,54.22,,,percent of total billed charges,,,,,,,,,146.55,,,percent of total billed charges,,,146.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,146.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.72,,,percent of total billed charges,,,146.55,,,percent of total billed charges,,,,,,,,,,,,,,,146.55,,,percent of total billed charges,,,146.55,,,percent of total billed charges,,,,,,,,,136.32,,,percent of total billed charges,,,,,,,,,,,,,,,136.32,,,percent of total billed charges,,,136.32,,,percent of total billed charges,,,136.32,,,percent of total billed charges,,,109.91,,,percent of total billed charges,,,146.55,,,percent of total billed charges,,,146.55,,,percent of total billed charges,,,146.55,,,percent of total billed charges,,,,,,,,,102.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,86.35,,,percent of total billed charges,,
ACETAMINOPHEN IV 1000MG/100ML,2500006376,CDM,636,RC,J0138,HCPCS,781315695,NDC,999,EAPG,,outpatient,facility,100,UN,146.55,146.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACYCLOVIR 200 MG CAP,2500006500,CDM,637,RC,904578961,NDC,,,,,,inpatient,facility,200,UN,0.43,0.43,0.03,0.43,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,
ACYCLOVIR 200 MG CAP,2500006500,CDM,637,RC,904578961,NDC,,,,,,outpatient,facility,200,UN,0.43,0.43,0.03,548.68,,0.3,,,percent of total billed charges,,,0.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.43,,,percent of total billed charges,,,0.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.16,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.43,,,fee schedule,,,0.43,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,0.25,,,percent of total billed charges,,,548.68,,,per diem,,,0.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.43,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,0.16,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.25,,,percent of total billed charges,,
ACYCLOVIR 200 MG CAP,2500006500,CDM,637,RC,904578961,NDC,999,EAPG,,,,outpatient,facility,200,UN,0.43,0.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACYCLOVIR 800 MG TAB,2500006508,CDM,637,RC,3172277801,NDC,,,,,,inpatient,facility,800,UN,13.93,13.93,1.11,13.93,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,13.93,,,percent of total billed charges,,,7.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.36,,,percent of total billed charges,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,11.84,,,percent of total billed charges,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.21,,,percent of total billed charges,,
ACYCLOVIR 800 MG TAB,2500006508,CDM,637,RC,3172277801,NDC,,,,,,outpatient,facility,800,UN,13.93,13.93,1.11,548.68,,9.88,,,percent of total billed charges,,,3.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.93,,,percent of total billed charges,,,8.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.93,,,fee schedule,,,13.93,,,percent of total billed charges,,,,,,,,,13.93,,,percent of total billed charges,,,8.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,7.52,,,percent of total billed charges,,,7.24,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,8.22,,,percent of total billed charges,,,548.68,,,per diem,,,13.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.93,,,percent of total billed charges,,,11.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.4,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.4,,,percent of total billed charges,,,11.27,,,percent of total billed charges,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,,,,,,,5.15,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,,,,,,,13.93,,,percent of total billed charges,,,13.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.11,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,12.96,,,percent of total billed charges,,,,,,,,,,,,,,,12.96,,,percent of total billed charges,,,12.96,,,percent of total billed charges,,,12.96,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,,,,,,,9.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.21,,,percent of total billed charges,,
ACYCLOVIR 800 MG TAB,2500006508,CDM,637,RC,3172277801,NDC,999,EAPG,,,,outpatient,facility,800,UN,13.93,13.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUTEROL 2 MG TAB,2500006560,CDM,637,RC,5107965720,NDC,,,,,,inpatient,facility,2,UN,23.26,23.26,1.86,23.26,,,,,,,,,,,,,,23.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.26,,,percent of total billed charges,,,,,,,,,23.26,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.96,,,percent of total billed charges,,,,,,,,,,,,,,,23.26,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,23.26,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,23.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,23.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.7,,,percent of total billed charges,,
ALBUTEROL 2 MG TAB,2500006560,CDM,637,RC,5107965720,NDC,,,,,,outpatient,facility,2,UN,23.26,23.26,1.86,548.68,,16.49,,,percent of total billed charges,,,5.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,23.26,,,percent of total billed charges,,,14.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,16.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,16.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,23.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.51,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,23.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,23.26,,,fee schedule,,,23.26,,,percent of total billed charges,,,,,,,,,23.26,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,12.56,,,percent of total billed charges,,,12.1,,,percent of total billed charges,,,12.79,,,percent of total billed charges,,,,,,,,,13.72,,,percent of total billed charges,,,548.68,,,per diem,,,23.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,23.26,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.35,,,percent of total billed charges,,,23.26,,,percent of total billed charges,,,23.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.69,,,percent of total billed charges,,,18.82,,,percent of total billed charges,,,,,,,,,,,,,,,9.3,,,percent of total billed charges,,,,,,,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,23.26,,,percent of total billed charges,,,23.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.86,,,percent of total billed charges,,,23.26,,,percent of total billed charges,,,,,,,,,,,,,,,23.26,,,percent of total billed charges,,,23.26,,,percent of total billed charges,,,,,,,,,21.64,,,percent of total billed charges,,,,,,,,,,,,,,,21.64,,,percent of total billed charges,,,21.64,,,percent of total billed charges,,,21.64,,,percent of total billed charges,,,17.45,,,percent of total billed charges,,,23.26,,,percent of total billed charges,,,23.26,,,percent of total billed charges,,,23.26,,,percent of total billed charges,,,,,,,,,16.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.7,,,percent of total billed charges,,
ALBUTEROL 2 MG TAB,2500006560,CDM,637,RC,5107965720,NDC,999,EAPG,,,,outpatient,facility,2,UN,23.26,23.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUTEROL 18 GM INH,2500006577,CDM,637,RC,6699301968,NDC,,,,,,inpatient,facility,200,UN,198,198,15.84,198,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,198,,,percent of total billed charges,,,101.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,168.3,,,percent of total billed charges,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,105.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,15.84,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.66,,,percent of total billed charges,,
ALBUTEROL 18 GM INH,2500006577,CDM,637,RC,6699301968,NDC,,,,,,outpatient,facility,200,UN,198,198,15.84,548.68,,140.4,,,percent of total billed charges,,,48.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,198,,,percent of total billed charges,,,124.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,139.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,139.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,72.47,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,198,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,198,,,fee schedule,,,198,,,percent of total billed charges,,,,,,,,,198,,,percent of total billed charges,,,121.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,,,,,,,,,,,106.92,,,percent of total billed charges,,,102.96,,,percent of total billed charges,,,108.9,,,percent of total billed charges,,,,,,,,,116.82,,,percent of total billed charges,,,548.68,,,per diem,,,198,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,198,,,percent of total billed charges,,,168.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,105.16,,,percent of total billed charges,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.57,,,percent of total billed charges,,,160.22,,,percent of total billed charges,,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,,,,,,,73.26,,,percent of total billed charges,,,73.26,,,percent of total billed charges,,,,,,,,,198,,,percent of total billed charges,,,198,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,198,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.84,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,184.18,,,percent of total billed charges,,,,,,,,,,,,,,,184.18,,,percent of total billed charges,,,184.18,,,percent of total billed charges,,,184.18,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,138.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,116.66,,,percent of total billed charges,,
ALBUTEROL 18 GM INH,2500006577,CDM,637,RC,6699301968,NDC,999,EAPG,,,,outpatient,facility,200,UN,198,198,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOPURINOL 100 MG TAB,2500006630,CDM,637,RC,904704161,NDC,,,,,,inpatient,facility,100,GR,1.09,1.09,0.09,1.09,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,
ALLOPURINOL 100 MG TAB,2500006630,CDM,637,RC,904704161,NDC,,,,,,outpatient,facility,100,GR,1.09,1.09,0.09,548.68,,0.77,,,percent of total billed charges,,,0.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.09,,,percent of total billed charges,,,0.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.09,,,fee schedule,,,1.09,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,0.64,,,percent of total billed charges,,,548.68,,,per diem,,,1.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.09,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.64,,,percent of total billed charges,,
ALLOPURINOL 100 MG TAB,2500006630,CDM,637,RC,904704161,NDC,999,EAPG,,,,outpatient,facility,100,GR,1.09,1.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALLOPURINOL 300 MG TAB,2500006633,CDM,637,RC,904657261,NDC,,,,,,inpatient,facility,300,UN,2.21,2.21,0.18,2.21,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,
ALLOPURINOL 300 MG TAB,2500006633,CDM,637,RC,904657261,NDC,,,,,,outpatient,facility,300,UN,2.21,2.21,0.18,548.68,,1.57,,,percent of total billed charges,,,0.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.21,,,percent of total billed charges,,,1.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.81,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.21,,,fee schedule,,,2.21,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,1.3,,,percent of total billed charges,,,548.68,,,per diem,,,2.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.21,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,2.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.3,,,percent of total billed charges,,
ALLOPURINOL 300 MG TAB,2500006633,CDM,637,RC,904657261,NDC,999,EAPG,,,,outpatient,facility,300,UN,2.21,2.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALPRAZOLAM 0.25 MG TAB,2500006660,CDM,637,RC,6586267601,NDC,,,,,,inpatient,facility,0.25,UN,2.31,2.31,0.18,2.31,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,
ALPRAZOLAM 0.25 MG TAB,2500006660,CDM,637,RC,6586267601,NDC,,,,,,outpatient,facility,0.25,UN,2.31,2.31,0.18,548.68,,1.64,,,percent of total billed charges,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.31,,,percent of total billed charges,,,1.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.85,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.31,,,fee schedule,,,2.31,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,,,,,,,1.36,,,percent of total billed charges,,,548.68,,,per diem,,,2.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.31,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,0.85,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,2.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.36,,,percent of total billed charges,,
ALPRAZOLAM 0.25 MG TAB,2500006660,CDM,637,RC,6586267601,NDC,999,EAPG,,,,outpatient,facility,0.25,UN,2.31,2.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALPRAZOLAM 0.5 MG TAB,2500006662,CDM,637,RC,6586267701,NDC,,,,,,inpatient,facility,0.5,UN,3.07,3.07,0.25,3.07,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,3.07,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,
ALPRAZOLAM 0.5 MG TAB,2500006662,CDM,637,RC,6586267701,NDC,,,,,,outpatient,facility,0.5,UN,3.07,3.07,0.25,548.68,,2.18,,,percent of total billed charges,,,0.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.07,,,percent of total billed charges,,,1.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.12,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.07,,,fee schedule,,,3.07,,,percent of total billed charges,,,,,,,,,3.07,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,1.69,,,percent of total billed charges,,,,,,,,,1.81,,,percent of total billed charges,,,548.68,,,per diem,,,3.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.07,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.07,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,1.14,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,3.07,,,percent of total billed charges,,,3.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.25,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,2.86,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.81,,,percent of total billed charges,,
ALPRAZOLAM 0.5 MG TAB,2500006662,CDM,637,RC,6586267701,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,3.07,3.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMANTADINE 100 MG CAP,2500006762,CDM,637,RC,G9017,HCPCS,904704206,NDC,,,,inpatient,facility,100,UN,4.62,4.62,0.37,4.62,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,4.62,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,2.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,
AMANTADINE 100 MG CAP,2500006762,CDM,637,RC,G9017,HCPCS,904704206,NDC,,,,outpatient,facility,100,UN,4.62,4.62,0.37,548.68,,3.28,,,percent of total billed charges,,,1.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.62,,,percent of total billed charges,,,2.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.69,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.62,,,fee schedule,,,4.62,,,percent of total billed charges,,,,,,,,,4.62,,,percent of total billed charges,,,2.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.29,,,percent of total billed charges,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,2.73,,,percent of total billed charges,,,548.68,,,per diem,,,4.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.62,,,percent of total billed charges,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,3.74,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,1.71,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,4.62,,,percent of total billed charges,,,4.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.37,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,4.3,,,percent of total billed charges,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,3.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.72,,,percent of total billed charges,,
AMANTADINE 100 MG CAP,2500006762,CDM,637,RC,G9017,HCPCS,904704206,NDC,999,EAPG,,outpatient,facility,100,UN,4.62,4.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMILORIDE HCL 5 MG TAB,2500006790,CDM,637,RC,574029201,NDC,,,,,,inpatient,facility,5,UN,0.73,0.73,0.06,0.73,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,0.73,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,
AMILORIDE HCL 5 MG TAB,2500006790,CDM,637,RC,574029201,NDC,,,,,,outpatient,facility,5,UN,0.73,0.73,0.06,548.68,,0.52,,,percent of total billed charges,,,0.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.73,,,percent of total billed charges,,,0.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.27,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.73,,,fee schedule,,,0.73,,,percent of total billed charges,,,,,,,,,0.73,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,548.68,,,per diem,,,0.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.73,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,0.73,,,percent of total billed charges,,,0.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,0.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.43,,,percent of total billed charges,,
AMILORIDE HCL 5 MG TAB,2500006790,CDM,637,RC,574029201,NDC,999,EAPG,,,,outpatient,facility,5,UN,0.73,0.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMINO ACIDS 5 /D15 1000 ML,2500006805,CDM,258,RC,338113703,NDC,,,,,,inpatient,facility,1000,UN,265.32,265.32,21.23,265.32,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,265.32,,,percent of total billed charges,,,135.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,225.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.19,,,percent of total billed charges,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,225.52,,,percent of total billed charges,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,140.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,21.23,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.33,,,percent of total billed charges,,
AMINO ACIDS 5 /D15 1000 ML,2500006805,CDM,258,RC,338113703,NDC,,,,,,outpatient,facility,1000,UN,265.32,265.32,21.23,548.68,,188.14,,,percent of total billed charges,,,64.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,265.32,,,percent of total billed charges,,,166.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,186.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,186.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,97.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,265.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,265.32,,,fee schedule,,,265.32,,,percent of total billed charges,,,,,,,,,265.32,,,percent of total billed charges,,,162.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,156.54,,,percent of total billed charges,,,548.68,,,per diem,,,265.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,265.32,,,percent of total billed charges,,,225.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.91,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.98,,,percent of total billed charges,,,214.7,,,percent of total billed charges,,,,,,,,,,,,,,,106.13,,,percent of total billed charges,,,,,,,,,106.13,,,percent of total billed charges,,,106.13,,,percent of total billed charges,,,,,,,,,265.32,,,percent of total billed charges,,,265.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,265.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.23,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,,,,,,,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,106.13,,,percent of total billed charges,,,,,,,,,,,,,,,106.13,,,percent of total billed charges,,,106.13,,,percent of total billed charges,,,106.13,,,percent of total billed charges,,,198.99,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,265.32,,,percent of total billed charges,,,,,,,,,186.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,156.33,,,percent of total billed charges,,
AMINO ACIDS 5 /D15 1000 ML,2500006805,CDM,258,RC,338113703,NDC,999,EAPG,,,,outpatient,facility,1000,UN,265.32,265.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMINO ACIDS 5 /D15 1000ML LYTE,2500006806,CDM,258,RC,338114703,NDC,,,,,,inpatient,facility,1000,UN,282.68,282.68,22.61,282.68,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,282.68,,,percent of total billed charges,,,144.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.61,,,percent of total billed charges,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,240.28,,,percent of total billed charges,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,150.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,22.61,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.56,,,percent of total billed charges,,
AMINO ACIDS 5 /D15 1000ML LYTE,2500006806,CDM,258,RC,338114703,NDC,,,,,,outpatient,facility,1000,UN,282.68,282.68,22.61,548.68,,200.45,,,percent of total billed charges,,,68.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,282.68,,,percent of total billed charges,,,177.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,198.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,198.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,103.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,282.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,282.68,,,fee schedule,,,282.68,,,percent of total billed charges,,,,,,,,,282.68,,,percent of total billed charges,,,173.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,166.78,,,percent of total billed charges,,,548.68,,,per diem,,,282.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,282.68,,,percent of total billed charges,,,240.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.13,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.7,,,percent of total billed charges,,,228.74,,,percent of total billed charges,,,,,,,,,,,,,,,113.07,,,percent of total billed charges,,,,,,,,,113.07,,,percent of total billed charges,,,113.07,,,percent of total billed charges,,,,,,,,,282.68,,,percent of total billed charges,,,282.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,282.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.61,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,113.07,,,percent of total billed charges,,,,,,,,,,,,,,,113.07,,,percent of total billed charges,,,113.07,,,percent of total billed charges,,,113.07,,,percent of total billed charges,,,212.01,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,198.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,166.56,,,percent of total billed charges,,
AMINO ACIDS 5 /D15 1000ML LYTE,2500006806,CDM,258,RC,338114703,NDC,999,EAPG,,,,outpatient,facility,1000,UN,282.68,282.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMINO ACIDS 5 /D20 2000ML LYTE,2500006808,CDM,258,RC,338112504,NDC,,,,,,inpatient,facility,2000,UN,287.03,287.03,22.96,287.03,,,,,,,,,,,,,,287.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.03,,,percent of total billed charges,,,,,,,,,287.03,,,percent of total billed charges,,,146.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,244.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.22,,,percent of total billed charges,,,,,,,,,,,,,,,287.03,,,percent of total billed charges,,,243.98,,,percent of total billed charges,,,,,,,,,,,,,,,287.03,,,percent of total billed charges,,,152.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,287.03,,,percent of total billed charges,,,,,,,,,,,,,,,22.96,,,percent of total billed charges,,,287.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,287.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.12,,,percent of total billed charges,,
AMINO ACIDS 5 /D20 2000ML LYTE,2500006808,CDM,258,RC,338112504,NDC,,,,,,outpatient,facility,2000,UN,287.03,287.03,22.96,548.68,,203.53,,,percent of total billed charges,,,70.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,287.03,,,percent of total billed charges,,,179.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,201.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,201.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,287.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,105.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,287.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,287.03,,,fee schedule,,,287.03,,,percent of total billed charges,,,,,,,,,287.03,,,percent of total billed charges,,,175.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,204.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,169.35,,,percent of total billed charges,,,548.68,,,per diem,,,287.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,287.03,,,percent of total billed charges,,,243.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,152.44,,,percent of total billed charges,,,287.03,,,percent of total billed charges,,,287.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.63,,,percent of total billed charges,,,232.26,,,percent of total billed charges,,,,,,,,,,,,,,,114.81,,,percent of total billed charges,,,,,,,,,114.81,,,percent of total billed charges,,,114.81,,,percent of total billed charges,,,,,,,,,287.03,,,percent of total billed charges,,,287.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,287.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.96,,,percent of total billed charges,,,287.03,,,percent of total billed charges,,,,,,,,,,,,,,,287.03,,,percent of total billed charges,,,287.03,,,percent of total billed charges,,,,,,,,,114.81,,,percent of total billed charges,,,,,,,,,,,,,,,114.81,,,percent of total billed charges,,,114.81,,,percent of total billed charges,,,114.81,,,percent of total billed charges,,,215.27,,,percent of total billed charges,,,287.03,,,percent of total billed charges,,,287.03,,,percent of total billed charges,,,287.03,,,percent of total billed charges,,,,,,,,,201.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,169.12,,,percent of total billed charges,,
AMINO ACIDS 5 /D20 2000ML LYTE,2500006808,CDM,258,RC,338112504,NDC,999,EAPG,,,,outpatient,facility,2000,UN,287.03,287.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMINOCAPROIC 500 MG TAB,2500006850,CDM,637,RC,6931523103,NDC,,,,,,inpatient,facility,500,UN,73.92,73.92,5.91,73.92,,,,,,,,,,,,,,73.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.92,,,percent of total billed charges,,,,,,,,,73.92,,,percent of total billed charges,,,37.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.35,,,percent of total billed charges,,,,,,,,,,,,,,,73.92,,,percent of total billed charges,,,62.83,,,percent of total billed charges,,,,,,,,,,,,,,,73.92,,,percent of total billed charges,,,39.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,73.92,,,percent of total billed charges,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.55,,,percent of total billed charges,,
AMINOCAPROIC 500 MG TAB,2500006850,CDM,637,RC,6931523103,NDC,,,,,,outpatient,facility,500,UN,73.92,73.92,5.91,548.68,,52.42,,,percent of total billed charges,,,18.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,73.92,,,percent of total billed charges,,,46.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,51.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,51.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,73.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,27.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,73.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,73.92,,,fee schedule,,,73.92,,,percent of total billed charges,,,,,,,,,73.92,,,percent of total billed charges,,,45.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.67,,,percent of total billed charges,,,,,,,,,,,,,,,39.92,,,percent of total billed charges,,,38.44,,,percent of total billed charges,,,40.66,,,percent of total billed charges,,,,,,,,,43.61,,,percent of total billed charges,,,548.68,,,per diem,,,73.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,73.92,,,percent of total billed charges,,,62.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.26,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.87,,,percent of total billed charges,,,59.82,,,percent of total billed charges,,,,,,,,,,,,,,,29.57,,,percent of total billed charges,,,,,,,,,27.35,,,percent of total billed charges,,,27.35,,,percent of total billed charges,,,,,,,,,73.92,,,percent of total billed charges,,,73.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,73.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.91,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,,,,,,,,,,,,,73.92,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,,,,,,,68.76,,,percent of total billed charges,,,,,,,,,,,,,,,68.76,,,percent of total billed charges,,,68.76,,,percent of total billed charges,,,68.76,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,,,,,,,51.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,43.55,,,percent of total billed charges,,
AMINOCAPROIC 500 MG TAB,2500006850,CDM,637,RC,6931523103,NDC,999,EAPG,,,,outpatient,facility,500,UN,73.92,73.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMIODARONE 200 MG TAB,2500006880,CDM,637,RC,904699361,NDC,,,,,,inpatient,facility,200,UN,0.99,0.99,0.08,0.99,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
AMIODARONE 200 MG TAB,2500006880,CDM,637,RC,904699361,NDC,,,,,,outpatient,facility,200,UN,0.99,0.99,0.08,548.68,,0.7,,,percent of total billed charges,,,0.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.99,,,percent of total billed charges,,,0.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.99,,,fee schedule,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,0.58,,,percent of total billed charges,,,548.68,,,per diem,,,0.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.99,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,0.37,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
AMIODARONE 200 MG TAB,2500006880,CDM,637,RC,904699361,NDC,999,EAPG,,,,outpatient,facility,200,UN,0.99,0.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMIODARONE HCL 150 MG/3 ML AMP,2500006885,CDM,636,RC,J0282,HCPCS,143987525,NDC,,,,inpatient,facility,3,UN,6.6,6.6,0.53,6.6,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,6.6,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,
AMIODARONE HCL 150 MG/3 ML AMP,2500006885,CDM,636,RC,J0282,HCPCS,143987525,NDC,,,,outpatient,facility,3,UN,6.6,6.6,0.53,548.68,,4.68,,,percent of total billed charges,,,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.6,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.42,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.6,,,fee schedule,,,6.6,,,percent of total billed charges,,,,,,,,,6.6,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,3.89,,,percent of total billed charges,,,548.68,,,per diem,,,6.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.6,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,5.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6.6,,,percent of total billed charges,,,6.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.53,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,4.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.89,,,percent of total billed charges,,
AMIODARONE HCL 150 MG/3 ML AMP,2500006885,CDM,636,RC,J0282,HCPCS,143987525,NDC,435,EAPG,,outpatient,facility,3,UN,6.6,6.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMITRIPTYLINE HCL 10 MG TAB,2500006890,CDM,637,RC,1672917117,NDC,,,,,,inpatient,facility,10,UN,0.99,0.99,0.08,0.99,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
AMITRIPTYLINE HCL 10 MG TAB,2500006890,CDM,637,RC,1672917117,NDC,,,,,,outpatient,facility,10,UN,0.99,0.99,0.08,548.68,,0.7,,,percent of total billed charges,,,0.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.99,,,percent of total billed charges,,,0.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.99,,,fee schedule,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,0.58,,,percent of total billed charges,,,548.68,,,per diem,,,0.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.99,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,0.37,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
AMITRIPTYLINE HCL 10 MG TAB,2500006890,CDM,637,RC,1672917117,NDC,999,EAPG,,,,outpatient,facility,10,UN,0.99,0.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMITRIPTYLINE HCL 25 MG TAB,2500006892,CDM,637,RC,904020161,NDC,,,,,,inpatient,facility,25,UN,1.42,1.42,0.11,1.42,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,
AMITRIPTYLINE HCL 25 MG TAB,2500006892,CDM,637,RC,904020161,NDC,,,,,,outpatient,facility,25,UN,1.42,1.42,0.11,548.68,,1.01,,,percent of total billed charges,,,0.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.42,,,percent of total billed charges,,,0.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.52,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.42,,,fee schedule,,,1.42,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,0.84,,,percent of total billed charges,,,548.68,,,per diem,,,1.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.42,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,0.53,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,1.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.84,,,percent of total billed charges,,
AMITRIPTYLINE HCL 25 MG TAB,2500006892,CDM,637,RC,904020161,NDC,999,EAPG,,,,outpatient,facility,25,UN,1.42,1.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMLODIPINE BESYLATE 5 MG TAB,2500006915,CDM,637,RC,904637061,NDC,,,,,,inpatient,facility,5,UN,0.26,0.26,0.02,0.26,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,
AMLODIPINE BESYLATE 5 MG TAB,2500006915,CDM,637,RC,904637061,NDC,,,,,,outpatient,facility,5,UN,0.26,0.26,0.02,548.68,,0.18,,,percent of total billed charges,,,0.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,0.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.26,,,fee schedule,,,0.26,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,0.15,,,percent of total billed charges,,,548.68,,,per diem,,,0.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.26,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,,,,,,,0.1,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.15,,,percent of total billed charges,,
AMLODIPINE BESYLATE 5 MG TAB,2500006915,CDM,637,RC,904637061,NDC,999,EAPG,,,,outpatient,facility,5,UN,0.26,0.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMOXICILLIN  250 MG CAP,2500006970,CDM,637,RC,781202001,NDC,,,,,,inpatient,facility,250,UN,0.83,0.83,0.07,0.83,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,
AMOXICILLIN  250 MG CAP,2500006970,CDM,637,RC,781202001,NDC,,,,,,outpatient,facility,250,UN,0.83,0.83,0.07,548.68,,0.59,,,percent of total billed charges,,,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.83,,,percent of total billed charges,,,0.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.83,,,fee schedule,,,0.83,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,548.68,,,per diem,,,0.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.83,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,0.31,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,0.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.49,,,percent of total billed charges,,
AMOXICILLIN  250 MG CAP,2500006970,CDM,637,RC,781202001,NDC,999,EAPG,,,,outpatient,facility,250,UN,0.83,0.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMOXICILLIN  500 MG CAP,2500006975,CDM,637,RC,781261301,NDC,,,,,,inpatient,facility,500,UN,1.42,1.42,0.11,1.42,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,
AMOXICILLIN  500 MG CAP,2500006975,CDM,637,RC,781261301,NDC,,,,,,outpatient,facility,500,UN,1.42,1.42,0.11,548.68,,1.01,,,percent of total billed charges,,,0.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.42,,,percent of total billed charges,,,0.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.52,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.42,,,fee schedule,,,1.42,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,0.84,,,percent of total billed charges,,,548.68,,,per diem,,,1.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.42,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,0.53,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,1.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.84,,,percent of total billed charges,,
AMOXICILLIN  500 MG CAP,2500006975,CDM,637,RC,781261301,NDC,999,EAPG,,,,outpatient,facility,500,UN,1.42,1.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMOXICILLIN 250MG/5 ML UD,2500006986,CDM,637,RC,781604146,NDC,,,,,,inpatient,facility,5,UN,1.09,1.09,0.09,1.09,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,
AMOXICILLIN 250MG/5 ML UD,2500006986,CDM,637,RC,781604146,NDC,,,,,,outpatient,facility,5,UN,1.09,1.09,0.09,548.68,,0.77,,,percent of total billed charges,,,0.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.09,,,percent of total billed charges,,,0.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.09,,,fee schedule,,,1.09,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,0.64,,,percent of total billed charges,,,548.68,,,per diem,,,1.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.09,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.64,,,percent of total billed charges,,
AMOXICILLIN 250MG/5 ML UD,2500006986,CDM,637,RC,781604146,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.09,1.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMOXICIL/CLAV 250 MG TAB,2500006990,CDM,637,RC,781187431,NDC,,,,,,inpatient,facility,250,UN,19.54,19.54,1.56,19.54,,,,,,,,,,,,,,19.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.54,,,percent of total billed charges,,,,,,,,,19.54,,,percent of total billed charges,,,9.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.72,,,percent of total billed charges,,,,,,,,,,,,,,,19.54,,,percent of total billed charges,,,16.61,,,percent of total billed charges,,,,,,,,,,,,,,,19.54,,,percent of total billed charges,,,10.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,19.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,19.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.51,,,percent of total billed charges,,
AMOXICIL/CLAV 250 MG TAB,2500006990,CDM,637,RC,781187431,NDC,,,,,,outpatient,facility,250,UN,19.54,19.54,1.56,548.68,,13.86,,,percent of total billed charges,,,4.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,19.54,,,percent of total billed charges,,,12.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,13.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,13.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,19.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.15,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,19.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,19.54,,,fee schedule,,,19.54,,,percent of total billed charges,,,,,,,,,19.54,,,percent of total billed charges,,,11.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,,,,,,,10.55,,,percent of total billed charges,,,10.16,,,percent of total billed charges,,,10.75,,,percent of total billed charges,,,,,,,,,11.53,,,percent of total billed charges,,,548.68,,,per diem,,,19.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,19.54,,,percent of total billed charges,,,16.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.38,,,percent of total billed charges,,,19.54,,,percent of total billed charges,,,19.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.18,,,percent of total billed charges,,,15.81,,,percent of total billed charges,,,,,,,,,,,,,,,7.82,,,percent of total billed charges,,,,,,,,,7.23,,,percent of total billed charges,,,7.23,,,percent of total billed charges,,,,,,,,,19.54,,,percent of total billed charges,,,19.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.56,,,percent of total billed charges,,,19.54,,,percent of total billed charges,,,,,,,,,,,,,,,19.54,,,percent of total billed charges,,,19.54,,,percent of total billed charges,,,,,,,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,19.54,,,percent of total billed charges,,,19.54,,,percent of total billed charges,,,19.54,,,percent of total billed charges,,,,,,,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.51,,,percent of total billed charges,,
AMOXICIL/CLAV 250 MG TAB,2500006990,CDM,637,RC,781187431,NDC,999,EAPG,,,,outpatient,facility,250,UN,19.54,19.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMOXICIL/CLAV 500 MG TAB,2500006991,CDM,637,RC,93227434,NDC,,,,,,inpatient,facility,500,UN,12.47,12.47,1,12.47,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,,,,,,,12.47,,,percent of total billed charges,,,6.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.48,,,percent of total billed charges,,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,10.6,,,percent of total billed charges,,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,6.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.35,,,percent of total billed charges,,
AMOXICIL/CLAV 500 MG TAB,2500006991,CDM,637,RC,93227434,NDC,,,,,,outpatient,facility,500,UN,12.47,12.47,1,548.68,,8.84,,,percent of total billed charges,,,3.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,12.47,,,percent of total billed charges,,,7.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,12.47,,,fee schedule,,,12.47,,,percent of total billed charges,,,,,,,,,12.47,,,percent of total billed charges,,,7.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.88,,,percent of total billed charges,,,,,,,,,,,,,,,6.73,,,percent of total billed charges,,,6.48,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,7.36,,,percent of total billed charges,,,548.68,,,per diem,,,12.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12.47,,,percent of total billed charges,,,10.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.62,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.41,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,,,,,,,,,,,,,4.99,,,percent of total billed charges,,,,,,,,,4.61,,,percent of total billed charges,,,4.61,,,percent of total billed charges,,,,,,,,,12.47,,,percent of total billed charges,,,12.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,,,,,,,11.6,,,percent of total billed charges,,,,,,,,,,,,,,,11.6,,,percent of total billed charges,,,11.6,,,percent of total billed charges,,,11.6,,,percent of total billed charges,,,9.35,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,,,,,,,8.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.35,,,percent of total billed charges,,
AMOXICIL/CLAV 500 MG TAB,2500006991,CDM,637,RC,93227434,NDC,999,EAPG,,,,outpatient,facility,500,UN,12.47,12.47,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMOXICIL/CLAV 875 MG TAB,2500006992,CDM,637,RC,93227534,NDC,,,,,,inpatient,facility,875,UN,16.67,16.67,1.33,16.67,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,16.67,,,percent of total billed charges,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,14.17,,,percent of total billed charges,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,8.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.82,,,percent of total billed charges,,
AMOXICIL/CLAV 875 MG TAB,2500006992,CDM,637,RC,93227534,NDC,,,,,,outpatient,facility,875,UN,16.67,16.67,1.33,548.68,,11.82,,,percent of total billed charges,,,4.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,16.67,,,percent of total billed charges,,,10.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,11.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,11.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,16.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,16.67,,,fee schedule,,,16.67,,,percent of total billed charges,,,,,,,,,16.67,,,percent of total billed charges,,,10.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,9,,,percent of total billed charges,,,8.67,,,percent of total billed charges,,,9.17,,,percent of total billed charges,,,,,,,,,9.84,,,percent of total billed charges,,,548.68,,,per diem,,,16.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,16.67,,,percent of total billed charges,,,14.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.85,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,6.67,,,percent of total billed charges,,,,,,,,,6.17,,,percent of total billed charges,,,6.17,,,percent of total billed charges,,,,,,,,,16.67,,,percent of total billed charges,,,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.33,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,15.51,,,percent of total billed charges,,,,,,,,,,,,,,,15.51,,,percent of total billed charges,,,15.51,,,percent of total billed charges,,,15.51,,,percent of total billed charges,,,12.5,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,11.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.82,,,percent of total billed charges,,
AMOXICIL/CLAV 875 MG TAB,2500006992,CDM,637,RC,93227534,NDC,999,EAPG,,,,outpatient,facility,875,UN,16.67,16.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMPHET ASP/AMPH/D-AMPH 5 MG XR,2500007001,CDM,637,RC,5766433688,NDC,,,,,,inpatient,facility,5,UN,3.63,3.63,0.29,3.63,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,,,,,,,3.63,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,
AMPHET ASP/AMPH/D-AMPH 5 MG XR,2500007001,CDM,637,RC,5766433688,NDC,,,,,,outpatient,facility,5,UN,3.63,3.63,0.29,548.68,,2.57,,,percent of total billed charges,,,0.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.63,,,percent of total billed charges,,,2.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.33,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.63,,,fee schedule,,,3.63,,,percent of total billed charges,,,,,,,,,3.63,,,percent of total billed charges,,,2.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2.14,,,percent of total billed charges,,,548.68,,,per diem,,,3.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.63,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,1.34,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,3.63,,,percent of total billed charges,,,3.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.29,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,3.38,,,percent of total billed charges,,,3.38,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.14,,,percent of total billed charges,,
AMPHET ASP/AMPH/D-AMPH 5 MG XR,2500007001,CDM,637,RC,5766433688,NDC,999,EAPG,,,,outpatient,facility,5,UN,3.63,3.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMPICILLIN 500 MG CAP,2500007012,CDM,637,RC,781214501,NDC,,,,,,inpatient,facility,500,UN,2.15,2.15,0.17,2.15,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,2.15,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,
AMPICILLIN 500 MG CAP,2500007012,CDM,637,RC,781214501,NDC,,,,,,outpatient,facility,500,UN,2.15,2.15,0.17,548.68,,1.52,,,percent of total billed charges,,,0.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.15,,,percent of total billed charges,,,1.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.79,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.15,,,fee schedule,,,2.15,,,percent of total billed charges,,,,,,,,,2.15,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,1.27,,,percent of total billed charges,,,548.68,,,per diem,,,2.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.15,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,0.8,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,2.15,,,percent of total billed charges,,,2.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.27,,,percent of total billed charges,,
AMPICILLIN 500 MG CAP,2500007012,CDM,637,RC,781214501,NDC,999,EAPG,,,,outpatient,facility,500,UN,2.15,2.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ANASTROZOLE 1 MG TAB,2500007080,CDM,637,RC,1672903510,NDC,,,,,,inpatient,facility,1,UN,43.89,43.89,3.51,43.89,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,,,,,,,43.89,,,percent of total billed charges,,,22.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.33,,,percent of total billed charges,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,37.31,,,percent of total billed charges,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,23.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.86,,,percent of total billed charges,,
ANASTROZOLE 1 MG TAB,2500007080,CDM,637,RC,1672903510,NDC,,,,,,outpatient,facility,1,UN,43.89,43.89,3.51,548.68,,31.12,,,percent of total billed charges,,,10.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,43.89,,,percent of total billed charges,,,27.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,30.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,30.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,16.06,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,43.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,43.89,,,fee schedule,,,43.89,,,percent of total billed charges,,,,,,,,,43.89,,,percent of total billed charges,,,26.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.27,,,percent of total billed charges,,,,,,,,,,,,,,,23.7,,,percent of total billed charges,,,22.82,,,percent of total billed charges,,,24.14,,,percent of total billed charges,,,,,,,,,25.9,,,percent of total billed charges,,,548.68,,,per diem,,,43.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,43.89,,,percent of total billed charges,,,37.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.31,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.61,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,,,,,,,,,,,,,17.56,,,percent of total billed charges,,,,,,,,,16.24,,,percent of total billed charges,,,16.24,,,percent of total billed charges,,,,,,,,,43.89,,,percent of total billed charges,,,43.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.51,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,43.89,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,,,,,,,40.83,,,percent of total billed charges,,,,,,,,,,,,,,,40.83,,,percent of total billed charges,,,40.83,,,percent of total billed charges,,,40.83,,,percent of total billed charges,,,32.92,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,,,,,,,30.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,25.86,,,percent of total billed charges,,
ANASTROZOLE 1 MG TAB,2500007080,CDM,637,RC,1672903510,NDC,999,EAPG,,,,outpatient,facility,1,UN,43.89,43.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
APIXABAN 2.5 MG TAB,2500007145,CDM,637,RC,3089331,NDC,,,,,,inpatient,facility,2.5,UN,32.7,32.7,2.62,32.7,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,,,,,,,32.7,,,percent of total billed charges,,,16.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.62,,,percent of total billed charges,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,27.8,,,percent of total billed charges,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,17.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.27,,,percent of total billed charges,,
APIXABAN 2.5 MG TAB,2500007145,CDM,637,RC,3089331,NDC,,,,,,outpatient,facility,2.5,UN,32.7,32.7,2.62,548.68,,23.19,,,percent of total billed charges,,,7.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,32.7,,,percent of total billed charges,,,20.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,22.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,22.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.97,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,32.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,32.7,,,fee schedule,,,32.7,,,percent of total billed charges,,,,,,,,,32.7,,,percent of total billed charges,,,20.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.3,,,percent of total billed charges,,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,,17,,,percent of total billed charges,,,17.99,,,percent of total billed charges,,,,,,,,,19.29,,,percent of total billed charges,,,548.68,,,per diem,,,32.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,32.7,,,percent of total billed charges,,,27.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.37,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.06,,,percent of total billed charges,,,26.46,,,percent of total billed charges,,,,,,,,,,,,,,,13.08,,,percent of total billed charges,,,,,,,,,12.1,,,percent of total billed charges,,,12.1,,,percent of total billed charges,,,,,,,,,32.7,,,percent of total billed charges,,,32.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,32.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.62,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,,,,,,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,24.53,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,,,,,,,22.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,19.27,,,percent of total billed charges,,
APIXABAN 2.5 MG TAB,2500007145,CDM,637,RC,3089331,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,32.7,32.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ARTIFICIAL TEARS OP SOLN 15ML,2500007162,CDM,637,RC,1747806012,NDC,,,,,,inpatient,facility,15,UN,18.17,18.17,1.45,18.17,,,,,,,,,,,,,,18.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.17,,,percent of total billed charges,,,,,,,,,18.17,,,percent of total billed charges,,,9.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.9,,,percent of total billed charges,,,,,,,,,,,,,,,18.17,,,percent of total billed charges,,,15.44,,,percent of total billed charges,,,,,,,,,,,,,,,18.17,,,percent of total billed charges,,,9.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,18.17,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,18.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.71,,,percent of total billed charges,,
ARTIFICIAL TEARS OP SOLN 15ML,2500007162,CDM,637,RC,1747806012,NDC,,,,,,outpatient,facility,15,UN,18.17,18.17,1.45,548.68,,12.88,,,percent of total billed charges,,,4.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,18.17,,,percent of total billed charges,,,11.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,12.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,12.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,18.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,18.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,18.17,,,fee schedule,,,18.17,,,percent of total billed charges,,,,,,,,,18.17,,,percent of total billed charges,,,11.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.95,,,percent of total billed charges,,,,,,,,,,,,,,,9.81,,,percent of total billed charges,,,9.45,,,percent of total billed charges,,,9.99,,,percent of total billed charges,,,,,,,,,10.72,,,percent of total billed charges,,,548.68,,,per diem,,,18.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,18.17,,,percent of total billed charges,,,15.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.65,,,percent of total billed charges,,,18.17,,,percent of total billed charges,,,18.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.26,,,percent of total billed charges,,,14.7,,,percent of total billed charges,,,,,,,,,,,,,,,7.27,,,percent of total billed charges,,,,,,,,,6.72,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,,,,,,,18.17,,,percent of total billed charges,,,18.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.45,,,percent of total billed charges,,,18.17,,,percent of total billed charges,,,,,,,,,,,,,,,18.17,,,percent of total billed charges,,,18.17,,,percent of total billed charges,,,,,,,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,13.63,,,percent of total billed charges,,,18.17,,,percent of total billed charges,,,18.17,,,percent of total billed charges,,,18.17,,,percent of total billed charges,,,,,,,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.71,,,percent of total billed charges,,
ARTIFICIAL TEARS OP SOLN 15ML,2500007162,CDM,637,RC,1747806012,NDC,999,EAPG,,,,outpatient,facility,15,UN,18.17,18.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ASCORBIC ACID 500 MG TAB,2500007183,CDM,637,RC,904052361,NDC,,,,,,inpatient,facility,500,UN,1.48,1.48,0.12,1.48,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,,,,,,,1.48,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,
ASCORBIC ACID 500 MG TAB,2500007183,CDM,637,RC,904052361,NDC,,,,,,outpatient,facility,500,UN,1.48,1.48,0.12,548.68,,1.05,,,percent of total billed charges,,,0.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.48,,,percent of total billed charges,,,0.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.54,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.48,,,fee schedule,,,1.48,,,percent of total billed charges,,,,,,,,,1.48,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,0.87,,,percent of total billed charges,,,548.68,,,per diem,,,1.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.48,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,,,,,,,1.48,,,percent of total billed charges,,,1.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.87,,,percent of total billed charges,,
ASCORBIC ACID 500 MG TAB,2500007183,CDM,637,RC,904052361,NDC,999,EAPG,,,,outpatient,facility,500,UN,1.48,1.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ASPIRIN 325 MG TAB,2500007194,CDM,637,RC,536105429,NDC,,,,,,inpatient,facility,325,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
ASPIRIN 325 MG TAB,2500007194,CDM,637,RC,536105429,NDC,,,,,,outpatient,facility,325,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
ASPIRIN 325 MG TAB,2500007194,CDM,637,RC,536105429,NDC,999,EAPG,,,,outpatient,facility,325,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ASPIRIN 300 MG SUPP,2500007197,CDM,637,RC,574703412,NDC,,,,,,inpatient,facility,300,UN,2.19,2.19,0.18,2.19,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,2.19,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,
ASPIRIN 300 MG SUPP,2500007197,CDM,637,RC,574703412,NDC,,,,,,outpatient,facility,300,UN,2.19,2.19,0.18,548.68,,1.55,,,percent of total billed charges,,,0.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.19,,,percent of total billed charges,,,1.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.8,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.19,,,fee schedule,,,2.19,,,percent of total billed charges,,,,,,,,,2.19,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,548.68,,,per diem,,,2.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.19,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,0.81,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,2.19,,,percent of total billed charges,,,2.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.29,,,percent of total billed charges,,
ASPIRIN 300 MG SUPP,2500007197,CDM,637,RC,574703412,NDC,999,EAPG,,,,outpatient,facility,300,UN,2.19,2.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ASPIRIN 81 MG TABEC,2500007206,CDM,637,RC,536123441,NDC,,,,,,inpatient,facility,81,UN,1.96,1.96,0.16,1.96,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,1.96,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,
ASPIRIN 81 MG TABEC,2500007206,CDM,637,RC,536123441,NDC,,,,,,outpatient,facility,81,UN,1.96,1.96,0.16,548.68,,1.39,,,percent of total billed charges,,,0.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.96,,,percent of total billed charges,,,1.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.72,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.96,,,fee schedule,,,1.96,,,percent of total billed charges,,,,,,,,,1.96,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,1.16,,,percent of total billed charges,,,548.68,,,per diem,,,1.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.96,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,1.96,,,percent of total billed charges,,,1.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.15,,,percent of total billed charges,,
ASPIRIN 81 MG TABEC,2500007206,CDM,637,RC,536123441,NDC,999,EAPG,,,,outpatient,facility,81,UN,1.96,1.96,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATENOLOL 50 MG TAB,2500007222,CDM,637,RC,5107968420,NDC,,,,,,inpatient,facility,50,UN,2.93,2.93,0.23,2.93,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,2.93,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,2.49,,,percent of total billed charges,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,
ATENOLOL 50 MG TAB,2500007222,CDM,637,RC,5107968420,NDC,,,,,,outpatient,facility,50,UN,2.93,2.93,0.23,548.68,,2.08,,,percent of total billed charges,,,0.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.93,,,percent of total billed charges,,,1.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.07,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.93,,,fee schedule,,,2.93,,,percent of total billed charges,,,,,,,,,2.93,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,1.73,,,percent of total billed charges,,,548.68,,,per diem,,,2.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.93,,,percent of total billed charges,,,2.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,2.93,,,percent of total billed charges,,,2.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,2.2,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.73,,,percent of total billed charges,,
ATENOLOL 50 MG TAB,2500007222,CDM,637,RC,5107968420,NDC,999,EAPG,,,,outpatient,facility,50,UN,2.93,2.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATORVASTATIN 10 MG TAB,2500007230,CDM,637,RC,6050525788,NDC,,,,,,inpatient,facility,10,UN,13.37,13.37,1.07,13.37,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,,,,,,,13.37,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.02,,,percent of total billed charges,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,11.36,,,percent of total billed charges,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,7.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.88,,,percent of total billed charges,,
ATORVASTATIN 10 MG TAB,2500007230,CDM,637,RC,6050525788,NDC,,,,,,outpatient,facility,10,UN,13.37,13.37,1.07,548.68,,9.48,,,percent of total billed charges,,,3.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.37,,,percent of total billed charges,,,8.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.89,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.37,,,fee schedule,,,13.37,,,percent of total billed charges,,,,,,,,,13.37,,,percent of total billed charges,,,8.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.53,,,percent of total billed charges,,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,6.95,,,percent of total billed charges,,,7.35,,,percent of total billed charges,,,,,,,,,7.89,,,percent of total billed charges,,,548.68,,,per diem,,,13.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.37,,,percent of total billed charges,,,11.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.1,,,percent of total billed charges,,,13.37,,,percent of total billed charges,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.02,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,5.35,,,percent of total billed charges,,,,,,,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,13.37,,,percent of total billed charges,,,13.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.07,,,percent of total billed charges,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,13.37,,,percent of total billed charges,,,,,,,,,12.44,,,percent of total billed charges,,,,,,,,,,,,,,,12.44,,,percent of total billed charges,,,12.44,,,percent of total billed charges,,,12.44,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,13.37,,,percent of total billed charges,,,13.37,,,percent of total billed charges,,,13.37,,,percent of total billed charges,,,,,,,,,9.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.88,,,percent of total billed charges,,
ATORVASTATIN 10 MG TAB,2500007230,CDM,637,RC,6050525788,NDC,999,EAPG,,,,outpatient,facility,10,UN,13.37,13.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATORVASTATIN 20 MG TAB,2500007232,CDM,637,RC,6050525798,NDC,,,,,,inpatient,facility,20,UN,19.04,19.04,1.52,19.04,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,,,,,,,19.04,,,percent of total billed charges,,,9.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.42,,,percent of total billed charges,,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,16.18,,,percent of total billed charges,,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,10.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.22,,,percent of total billed charges,,
ATORVASTATIN 20 MG TAB,2500007232,CDM,637,RC,6050525798,NDC,,,,,,outpatient,facility,20,UN,19.04,19.04,1.52,548.68,,13.5,,,percent of total billed charges,,,4.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,19.04,,,percent of total billed charges,,,11.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,13.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,13.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.97,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,19.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,19.04,,,fee schedule,,,19.04,,,percent of total billed charges,,,,,,,,,19.04,,,percent of total billed charges,,,11.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.57,,,percent of total billed charges,,,,,,,,,,,,,,,10.28,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,10.47,,,percent of total billed charges,,,,,,,,,11.23,,,percent of total billed charges,,,548.68,,,per diem,,,19.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,19.04,,,percent of total billed charges,,,16.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.11,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.84,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,7.62,,,percent of total billed charges,,,,,,,,,7.04,,,percent of total billed charges,,,7.04,,,percent of total billed charges,,,,,,,,,19.04,,,percent of total billed charges,,,19.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.52,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,,,,,,,17.71,,,percent of total billed charges,,,,,,,,,,,,,,,17.71,,,percent of total billed charges,,,17.71,,,percent of total billed charges,,,17.71,,,percent of total billed charges,,,14.28,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,,,,,,,13.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.22,,,percent of total billed charges,,
ATORVASTATIN 20 MG TAB,2500007232,CDM,637,RC,6050525798,NDC,999,EAPG,,,,outpatient,facility,20,UN,19.04,19.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATOVAQUONE 750 MG/5 ML,2500007245,CDM,637,RC,904706453,NDC,,,,,,inpatient,facility,5,UN,53.26,53.26,4.26,53.26,,,,,,,,,,,,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.26,,,percent of total billed charges,,,,,,,,,53.26,,,percent of total billed charges,,,27.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.96,,,percent of total billed charges,,,,,,,,,,,,,,,53.26,,,percent of total billed charges,,,45.27,,,percent of total billed charges,,,,,,,,,,,,,,,53.26,,,percent of total billed charges,,,28.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.38,,,percent of total billed charges,,
ATOVAQUONE 750 MG/5 ML,2500007245,CDM,637,RC,904706453,NDC,,,,,,outpatient,facility,5,UN,53.26,53.26,4.26,548.68,,37.77,,,percent of total billed charges,,,13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,53.26,,,percent of total billed charges,,,33.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,37.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,37.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,19.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,53.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,53.26,,,fee schedule,,,53.26,,,percent of total billed charges,,,,,,,,,53.26,,,percent of total billed charges,,,32.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.95,,,percent of total billed charges,,,,,,,,,,,,,,,28.76,,,percent of total billed charges,,,27.7,,,percent of total billed charges,,,29.29,,,percent of total billed charges,,,,,,,,,31.42,,,percent of total billed charges,,,548.68,,,per diem,,,53.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,53.26,,,percent of total billed charges,,,45.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.29,,,percent of total billed charges,,,53.26,,,percent of total billed charges,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.93,,,percent of total billed charges,,,43.1,,,percent of total billed charges,,,,,,,,,,,,,,,21.3,,,percent of total billed charges,,,,,,,,,19.71,,,percent of total billed charges,,,19.71,,,percent of total billed charges,,,,,,,,,53.26,,,percent of total billed charges,,,53.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,53.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.26,,,percent of total billed charges,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,53.26,,,percent of total billed charges,,,53.26,,,percent of total billed charges,,,,,,,,,49.54,,,percent of total billed charges,,,,,,,,,,,,,,,49.54,,,percent of total billed charges,,,49.54,,,percent of total billed charges,,,49.54,,,percent of total billed charges,,,39.95,,,percent of total billed charges,,,53.26,,,percent of total billed charges,,,53.26,,,percent of total billed charges,,,53.26,,,percent of total billed charges,,,,,,,,,37.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,31.38,,,percent of total billed charges,,
ATOVAQUONE 750 MG/5 ML,2500007245,CDM,637,RC,904706453,NDC,999,EAPG,,,,outpatient,facility,5,UN,53.26,53.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATROPINE SULF 1  OP SOLN 5 ML,2500007264,CDM,637,RC,65030355,NDC,,,,,,inpatient,facility,5,UN,267.7,267.7,21.42,267.7,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,,,,,,,267.7,,,percent of total billed charges,,,136.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.62,,,percent of total billed charges,,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,227.54,,,percent of total billed charges,,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,142.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,21.42,,,percent of total billed charges,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.73,,,percent of total billed charges,,
ATROPINE SULF 1  OP SOLN 5 ML,2500007264,CDM,637,RC,65030355,NDC,,,,,,outpatient,facility,5,UN,267.7,267.7,21.42,548.68,,189.83,,,percent of total billed charges,,,65.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,267.7,,,percent of total billed charges,,,167.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,188.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,188.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,97.98,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,267.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,267.7,,,fee schedule,,,267.7,,,percent of total billed charges,,,,,,,,,267.7,,,percent of total billed charges,,,164.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.74,,,percent of total billed charges,,,,,,,,,,,,,,,144.56,,,percent of total billed charges,,,139.2,,,percent of total billed charges,,,147.24,,,percent of total billed charges,,,,,,,,,157.94,,,percent of total billed charges,,,548.68,,,per diem,,,267.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,267.7,,,percent of total billed charges,,,227.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.18,,,percent of total billed charges,,,267.7,,,percent of total billed charges,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.59,,,percent of total billed charges,,,216.62,,,percent of total billed charges,,,,,,,,,,,,,,,107.08,,,percent of total billed charges,,,,,,,,,99.05,,,percent of total billed charges,,,99.05,,,percent of total billed charges,,,,,,,,,267.7,,,percent of total billed charges,,,267.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,267.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.42,,,percent of total billed charges,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,267.7,,,percent of total billed charges,,,,,,,,,249.01,,,percent of total billed charges,,,,,,,,,,,,,,,249.01,,,percent of total billed charges,,,249.01,,,percent of total billed charges,,,249.01,,,percent of total billed charges,,,200.77,,,percent of total billed charges,,,267.7,,,percent of total billed charges,,,267.7,,,percent of total billed charges,,,267.7,,,percent of total billed charges,,,,,,,,,187.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,157.73,,,percent of total billed charges,,
ATROPINE SULF 1  OP SOLN 5 ML,2500007264,CDM,637,RC,65030355,NDC,999,EAPG,,,,outpatient,facility,5,UN,267.7,267.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATROPINE SULF INJ 0.4 MG,2500007277,CDM,636,RC,J0461,HCPCS,517040125,NDC,,,,inpatient,facility,1,UN,26.4,26.4,2.11,26.4,,,,,,,,,,,,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.4,,,percent of total billed charges,,,,,,,,,26.4,,,percent of total billed charges,,,13.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.84,,,percent of total billed charges,,,,,,,,,,,,,,,26.4,,,percent of total billed charges,,,22.44,,,percent of total billed charges,,,,,,,,,,,,,,,26.4,,,percent of total billed charges,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.55,,,percent of total billed charges,,
ATROPINE SULF INJ 0.4 MG,2500007277,CDM,636,RC,J0461,HCPCS,517040125,NDC,,,,outpatient,facility,1,UN,26.4,26.4,0.02,548.68,,18.72,,,percent of total billed charges,,,6.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,26.4,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.66,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.02,,,fee schedule,,,26.4,,,fee schedule,,,26.4,,,percent of total billed charges,,,,,,,,,26.4,,,percent of total billed charges,,,16.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,15.58,,,percent of total billed charges,,,548.68,,,per diem,,,26.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,26.4,,,percent of total billed charges,,,22.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.02,,,percent of total billed charges,,,26.4,,,percent of total billed charges,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.81,,,percent of total billed charges,,,21.36,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,26.4,,,percent of total billed charges,,,26.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.11,,,percent of total billed charges,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,,26.4,,,percent of total billed charges,,,26.4,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.09,,,fee schedule,,,26.4,,,percent of total billed charges,,,26.4,,,percent of total billed charges,,,26.4,,,percent of total billed charges,,,,,,,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15.55,,,percent of total billed charges,,
ATROPINE SULF INJ 0.4 MG,2500007277,CDM,636,RC,J0461,HCPCS,517040125,NDC,496,EAPG,,outpatient,facility,1,UN,26.4,26.4,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AZELASTINE 137MCG SPRAY,2500007310,CDM,637,RC,5199181403,NDC,,,,,,inpatient,facility,30,UN,347.16,347.16,27.77,347.16,,,,,,,,,,,,,,347.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,347.16,,,percent of total billed charges,,,,,,,,,347.16,,,percent of total billed charges,,,177.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,295.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,208.3,,,percent of total billed charges,,,,,,,,,,,,,,,347.16,,,percent of total billed charges,,,295.09,,,percent of total billed charges,,,,,,,,,,,,,,,347.16,,,percent of total billed charges,,,184.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,347.16,,,percent of total billed charges,,,,,,,,,,,,,,,27.77,,,percent of total billed charges,,,347.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,347.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,204.55,,,percent of total billed charges,,
AZELASTINE 137MCG SPRAY,2500007310,CDM,637,RC,5199181403,NDC,,,,,,outpatient,facility,30,UN,347.16,347.16,27.77,548.68,,246.17,,,percent of total billed charges,,,84.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,347.16,,,percent of total billed charges,,,217.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,244.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,244.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,347.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,127.06,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,347.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,347.16,,,fee schedule,,,347.16,,,percent of total billed charges,,,,,,,,,347.16,,,percent of total billed charges,,,212.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247.35,,,percent of total billed charges,,,,,,,,,,,,,,,187.47,,,percent of total billed charges,,,180.52,,,percent of total billed charges,,,190.94,,,percent of total billed charges,,,,,,,,,204.82,,,percent of total billed charges,,,548.68,,,per diem,,,347.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,347.16,,,percent of total billed charges,,,295.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,184.38,,,percent of total billed charges,,,347.16,,,percent of total billed charges,,,347.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.19,,,percent of total billed charges,,,280.92,,,percent of total billed charges,,,,,,,,,,,,,,,138.86,,,percent of total billed charges,,,,,,,,,128.45,,,percent of total billed charges,,,128.45,,,percent of total billed charges,,,,,,,,,347.16,,,percent of total billed charges,,,347.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,347.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.77,,,percent of total billed charges,,,347.16,,,percent of total billed charges,,,,,,,,,,,,,,,347.16,,,percent of total billed charges,,,347.16,,,percent of total billed charges,,,,,,,,,322.93,,,percent of total billed charges,,,,,,,,,,,,,,,322.93,,,percent of total billed charges,,,322.93,,,percent of total billed charges,,,322.93,,,percent of total billed charges,,,260.37,,,percent of total billed charges,,,347.16,,,percent of total billed charges,,,347.16,,,percent of total billed charges,,,347.16,,,percent of total billed charges,,,,,,,,,243.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,204.55,,,percent of total billed charges,,
AZELASTINE 137MCG SPRAY,2500007310,CDM,637,RC,5199181403,NDC,999,EAPG,,,,outpatient,facility,30,UN,347.16,347.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AZITHROMYCIN 250 MG TAB,2500007320,CDM,637,RC,Q0144,HCPCS,5976221981,NDC,,,,inpatient,facility,250,UN,4.09,4.09,0.33,4.09,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,4.09,,,percent of total billed charges,,,2.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,3.48,,,percent of total billed charges,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,
AZITHROMYCIN 250 MG TAB,2500007320,CDM,637,RC,Q0144,HCPCS,5976221981,NDC,,,,outpatient,facility,250,UN,4.09,4.09,0.33,548.68,,2.9,,,percent of total billed charges,,,1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.09,,,percent of total billed charges,,,35.92,,,fee schedule,,,33.98,,,fee schedule,,,,,,,,,33.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.5,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.09,,,fee schedule,,,4.09,,,percent of total billed charges,,,,,,,,,4.09,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,4.09,,,fee schedule,,,4.09,,,fee schedule,,,4.09,,,fee schedule,,,,,,,,,2.41,,,percent of total billed charges,,,548.68,,,per diem,,,4.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.09,,,percent of total billed charges,,,3.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,,,,,,,,4.09,,,fee schedule,,,4.09,,,fee schedule,,,,,,,,,4.09,,,percent of total billed charges,,,4.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.33,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,4.09,,,fee schedule,,,,,,,,,,,,,,,4.09,,,fee schedule,,,4.09,,,fee schedule,,,4.09,,,fee schedule,,,4.09,,,fee schedule,,,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.41,,,percent of total billed charges,,
AZITHROMYCIN 250 MG TAB,2500007320,CDM,637,RC,Q0144,HCPCS,5976221981,NDC,999,EAPG,,outpatient,facility,250,UN,4.09,4.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BACITRACIN OINT 0.9 GM PKT,2500007333,CDM,637,RC,5332908986,NDC,,,,,,inpatient,facility,0.9,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
BACITRACIN OINT 0.9 GM PKT,2500007333,CDM,637,RC,5332908986,NDC,,,,,,outpatient,facility,0.9,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
BACITRACIN OINT 0.9 GM PKT,2500007333,CDM,637,RC,5332908986,NDC,999,EAPG,,,,outpatient,facility,0.9,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BACITRACIN OINT 500 U/GM 30 GM,2500007336,CDM,637,RC,713028031,NDC,,,,,,inpatient,facility,30,UN,5.51,5.51,0.44,5.51,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,5.51,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.25,,,percent of total billed charges,,
BACITRACIN OINT 500 U/GM 30 GM,2500007336,CDM,637,RC,713028031,NDC,,,,,,outpatient,facility,30,UN,5.51,5.51,0.44,548.68,,3.91,,,percent of total billed charges,,,1.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.51,,,percent of total billed charges,,,3.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.02,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.51,,,fee schedule,,,5.51,,,percent of total billed charges,,,,,,,,,5.51,,,percent of total billed charges,,,3.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,3.25,,,percent of total billed charges,,,548.68,,,per diem,,,5.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.51,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.72,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,2.2,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,5.51,,,percent of total billed charges,,,5.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.44,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,5.13,,,percent of total billed charges,,,,,,,,,,,,,,,5.13,,,percent of total billed charges,,,5.13,,,percent of total billed charges,,,5.13,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,3.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.25,,,percent of total billed charges,,
BACITRACIN OINT 500 U/GM 30 GM,2500007336,CDM,637,RC,713028031,NDC,999,EAPG,,,,outpatient,facility,30,UN,5.51,5.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BACITRACIN/POLYM OP OINT 3.5GM,2500007341,CDM,637,RC,2420855555,NDC,,,,,,inpatient,facility,3.5,UN,94.55,94.55,7.56,94.55,,,,,,,,,,,,,,94.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.55,,,percent of total billed charges,,,,,,,,,94.55,,,percent of total billed charges,,,48.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,,,,,,,,,,,,,94.55,,,percent of total billed charges,,,80.37,,,percent of total billed charges,,,,,,,,,,,,,,,94.55,,,percent of total billed charges,,,50.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,94.55,,,percent of total billed charges,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,94.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.71,,,percent of total billed charges,,
BACITRACIN/POLYM OP OINT 3.5GM,2500007341,CDM,637,RC,2420855555,NDC,,,,,,outpatient,facility,3.5,UN,94.55,94.55,7.56,548.68,,67.05,,,percent of total billed charges,,,23.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,94.55,,,percent of total billed charges,,,59.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,66.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,66.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,94.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,34.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,94.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,94.55,,,fee schedule,,,94.55,,,percent of total billed charges,,,,,,,,,94.55,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.37,,,percent of total billed charges,,,,,,,,,,,,,,,51.06,,,percent of total billed charges,,,49.17,,,percent of total billed charges,,,52,,,percent of total billed charges,,,,,,,,,55.78,,,percent of total billed charges,,,548.68,,,per diem,,,94.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,94.55,,,percent of total billed charges,,,80.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,94.55,,,percent of total billed charges,,,94.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.78,,,percent of total billed charges,,,76.51,,,percent of total billed charges,,,,,,,,,,,,,,,37.82,,,percent of total billed charges,,,,,,,,,34.98,,,percent of total billed charges,,,34.98,,,percent of total billed charges,,,,,,,,,94.55,,,percent of total billed charges,,,94.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,94.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.56,,,percent of total billed charges,,,94.55,,,percent of total billed charges,,,,,,,,,,,,,,,94.55,,,percent of total billed charges,,,94.55,,,percent of total billed charges,,,,,,,,,87.95,,,percent of total billed charges,,,,,,,,,,,,,,,87.95,,,percent of total billed charges,,,87.95,,,percent of total billed charges,,,87.95,,,percent of total billed charges,,,70.91,,,percent of total billed charges,,,94.55,,,percent of total billed charges,,,94.55,,,percent of total billed charges,,,94.55,,,percent of total billed charges,,,,,,,,,66.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,55.71,,,percent of total billed charges,,
BACITRACIN/POLYM OP OINT 3.5GM,2500007341,CDM,637,RC,2420855555,NDC,999,EAPG,,,,outpatient,facility,3.5,UN,94.55,94.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BACLOFEN 10 MG TAB,2500007350,CDM,637,RC,904647561,NDC,,,,,,inpatient,facility,10,UN,1.38,1.38,0.11,1.38,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,1.38,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,
BACLOFEN 10 MG TAB,2500007350,CDM,637,RC,904647561,NDC,,,,,,outpatient,facility,10,UN,1.38,1.38,0.11,548.68,,0.98,,,percent of total billed charges,,,0.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.38,,,percent of total billed charges,,,0.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.51,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.38,,,fee schedule,,,1.38,,,percent of total billed charges,,,,,,,,,1.38,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,0.81,,,percent of total billed charges,,,548.68,,,per diem,,,1.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.38,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,0.51,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,1.38,,,percent of total billed charges,,,1.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,0.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.81,,,percent of total billed charges,,
BACLOFEN 10 MG TAB,2500007350,CDM,637,RC,904647561,NDC,999,EAPG,,,,outpatient,facility,10,UN,1.38,1.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BALANCED SALT SOLN OP IRR 15ML,2500007360,CDM,637,RC,65079515,NDC,,,,,,inpatient,facility,15,UN,40.13,40.13,3.21,40.13,,,,,,,,,,,,,,40.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.13,,,percent of total billed charges,,,,,,,,,40.13,,,percent of total billed charges,,,20.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.08,,,percent of total billed charges,,,,,,,,,,,,,,,40.13,,,percent of total billed charges,,,34.11,,,percent of total billed charges,,,,,,,,,,,,,,,40.13,,,percent of total billed charges,,,21.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,40.13,,,percent of total billed charges,,,,,,,,,,,,,,,3.21,,,percent of total billed charges,,,40.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.64,,,percent of total billed charges,,
BALANCED SALT SOLN OP IRR 15ML,2500007360,CDM,637,RC,65079515,NDC,,,,,,outpatient,facility,15,UN,40.13,40.13,3.21,548.68,,28.46,,,percent of total billed charges,,,9.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,40.13,,,percent of total billed charges,,,25.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,28.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,28.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,40.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,14.69,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,40.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,40.13,,,fee schedule,,,40.13,,,percent of total billed charges,,,,,,,,,40.13,,,percent of total billed charges,,,24.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.59,,,percent of total billed charges,,,,,,,,,,,,,,,21.67,,,percent of total billed charges,,,20.87,,,percent of total billed charges,,,22.07,,,percent of total billed charges,,,,,,,,,23.68,,,percent of total billed charges,,,548.68,,,per diem,,,40.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,40.13,,,percent of total billed charges,,,34.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.31,,,percent of total billed charges,,,40.13,,,percent of total billed charges,,,40.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.07,,,percent of total billed charges,,,32.47,,,percent of total billed charges,,,,,,,,,,,,,,,16.05,,,percent of total billed charges,,,,,,,,,14.85,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,,,,,,,40.13,,,percent of total billed charges,,,40.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.21,,,percent of total billed charges,,,40.13,,,percent of total billed charges,,,,,,,,,,,,,,,40.13,,,percent of total billed charges,,,40.13,,,percent of total billed charges,,,,,,,,,37.33,,,percent of total billed charges,,,,,,,,,,,,,,,37.33,,,percent of total billed charges,,,37.33,,,percent of total billed charges,,,37.33,,,percent of total billed charges,,,30.1,,,percent of total billed charges,,,40.13,,,percent of total billed charges,,,40.13,,,percent of total billed charges,,,40.13,,,percent of total billed charges,,,,,,,,,28.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,23.64,,,percent of total billed charges,,
BALANCED SALT SOLN OP IRR 15ML,2500007360,CDM,637,RC,65079515,NDC,999,EAPG,,,,outpatient,facility,15,UN,40.13,40.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BALANCED SALT SOLN OP IRR 30ML,2500007363,CDM,637,RC,65079515,NDC,,,,,,inpatient,facility,30,UN,65.8,65.8,5.26,65.8,,,,,,,,,,,,,,65.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.8,,,percent of total billed charges,,,,,,,,,65.8,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.48,,,percent of total billed charges,,,,,,,,,,,,,,,65.8,,,percent of total billed charges,,,55.93,,,percent of total billed charges,,,,,,,,,,,,,,,65.8,,,percent of total billed charges,,,34.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,65.8,,,percent of total billed charges,,,,,,,,,,,,,,,5.26,,,percent of total billed charges,,,65.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.77,,,percent of total billed charges,,
BALANCED SALT SOLN OP IRR 30ML,2500007363,CDM,637,RC,65079515,NDC,,,,,,outpatient,facility,30,UN,65.8,65.8,5.26,548.68,,46.66,,,percent of total billed charges,,,16.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,65.8,,,percent of total billed charges,,,41.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,46.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,46.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,65.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,24.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,65.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,65.8,,,fee schedule,,,65.8,,,percent of total billed charges,,,,,,,,,65.8,,,percent of total billed charges,,,40.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.88,,,percent of total billed charges,,,,,,,,,,,,,,,35.53,,,percent of total billed charges,,,34.22,,,percent of total billed charges,,,36.19,,,percent of total billed charges,,,,,,,,,38.82,,,percent of total billed charges,,,548.68,,,per diem,,,65.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,65.8,,,percent of total billed charges,,,55.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.95,,,percent of total billed charges,,,65.8,,,percent of total billed charges,,,65.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.39,,,percent of total billed charges,,,53.25,,,percent of total billed charges,,,,,,,,,,,,,,,26.32,,,percent of total billed charges,,,,,,,,,24.35,,,percent of total billed charges,,,24.35,,,percent of total billed charges,,,,,,,,,65.8,,,percent of total billed charges,,,65.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,65.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.26,,,percent of total billed charges,,,65.8,,,percent of total billed charges,,,,,,,,,,,,,,,65.8,,,percent of total billed charges,,,65.8,,,percent of total billed charges,,,,,,,,,61.21,,,percent of total billed charges,,,,,,,,,,,,,,,61.21,,,percent of total billed charges,,,61.21,,,percent of total billed charges,,,61.21,,,percent of total billed charges,,,49.35,,,percent of total billed charges,,,65.8,,,percent of total billed charges,,,65.8,,,percent of total billed charges,,,65.8,,,percent of total billed charges,,,,,,,,,46.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,38.77,,,percent of total billed charges,,
BALANCED SALT SOLN OP IRR 30ML,2500007363,CDM,637,RC,65079515,NDC,999,EAPG,,,,outpatient,facility,30,UN,65.8,65.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BELLADONNA/PHENOBARB 5 ML UDC,2500007410,CDM,637,RC,6668906310,NDC,,,,,,inpatient,facility,5,UN,187.11,187.11,14.97,187.11,,,,,,,,,,,,,,187.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.11,,,percent of total billed charges,,,,,,,,,187.11,,,percent of total billed charges,,,95.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.27,,,percent of total billed charges,,,,,,,,,,,,,,,187.11,,,percent of total billed charges,,,159.04,,,percent of total billed charges,,,,,,,,,,,,,,,187.11,,,percent of total billed charges,,,99.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,187.11,,,percent of total billed charges,,,,,,,,,,,,,,,14.97,,,percent of total billed charges,,,187.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,187.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.25,,,percent of total billed charges,,
BELLADONNA/PHENOBARB 5 ML UDC,2500007410,CDM,637,RC,6668906310,NDC,,,,,,outpatient,facility,5,UN,187.11,187.11,14.97,548.68,,132.68,,,percent of total billed charges,,,45.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,187.11,,,percent of total billed charges,,,117.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,131.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,131.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,187.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,68.48,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,187.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,187.11,,,fee schedule,,,187.11,,,percent of total billed charges,,,,,,,,,187.11,,,percent of total billed charges,,,114.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.32,,,percent of total billed charges,,,,,,,,,,,,,,,101.04,,,percent of total billed charges,,,97.3,,,percent of total billed charges,,,102.91,,,percent of total billed charges,,,,,,,,,110.39,,,percent of total billed charges,,,548.68,,,per diem,,,187.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,187.11,,,percent of total billed charges,,,159.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,99.37,,,percent of total billed charges,,,187.11,,,percent of total billed charges,,,187.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.22,,,percent of total billed charges,,,151.41,,,percent of total billed charges,,,,,,,,,,,,,,,74.84,,,percent of total billed charges,,,,,,,,,69.23,,,percent of total billed charges,,,69.23,,,percent of total billed charges,,,,,,,,,187.11,,,percent of total billed charges,,,187.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,187.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.97,,,percent of total billed charges,,,187.11,,,percent of total billed charges,,,,,,,,,,,,,,,187.11,,,percent of total billed charges,,,187.11,,,percent of total billed charges,,,,,,,,,174.05,,,percent of total billed charges,,,,,,,,,,,,,,,174.05,,,percent of total billed charges,,,174.05,,,percent of total billed charges,,,174.05,,,percent of total billed charges,,,140.33,,,percent of total billed charges,,,187.11,,,percent of total billed charges,,,187.11,,,percent of total billed charges,,,187.11,,,percent of total billed charges,,,,,,,,,131.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,110.25,,,percent of total billed charges,,
BELLADONNA/PHENOBARB 5 ML UDC,2500007410,CDM,637,RC,6668906310,NDC,999,EAPG,,,,outpatient,facility,5,UN,187.11,187.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BELLADONNA/OPIUM 60 MG SUP,2500007420,CDM,637,RC,,,,,,,,inpatient,facility,1,UN,110.39,110.39,8.83,110.39,,,,,,,,,,,,,,110.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.39,,,percent of total billed charges,,,,,,,,,110.39,,,percent of total billed charges,,,56.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.23,,,percent of total billed charges,,,,,,,,,,,,,,,110.39,,,percent of total billed charges,,,93.83,,,percent of total billed charges,,,,,,,,,,,,,,,110.39,,,percent of total billed charges,,,58.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,110.39,,,percent of total billed charges,,,,,,,,,,,,,,,8.83,,,percent of total billed charges,,,110.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,110.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.04,,,percent of total billed charges,,
BELLADONNA/OPIUM 60 MG SUP,2500007420,CDM,637,RC,,,,,,,,outpatient,facility,1,UN,110.39,110.39,8.83,548.68,,78.28,,,percent of total billed charges,,,26.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,110.39,,,percent of total billed charges,,,69.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,77.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,77.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,110.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,40.4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,110.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,110.39,,,fee schedule,,,110.39,,,percent of total billed charges,,,,,,,,,110.39,,,percent of total billed charges,,,67.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.65,,,percent of total billed charges,,,,,,,,,,,,,,,59.61,,,percent of total billed charges,,,57.4,,,percent of total billed charges,,,60.71,,,percent of total billed charges,,,,,,,,,65.13,,,percent of total billed charges,,,548.68,,,per diem,,,110.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,110.39,,,percent of total billed charges,,,93.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.63,,,percent of total billed charges,,,110.39,,,percent of total billed charges,,,110.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.47,,,percent of total billed charges,,,89.33,,,percent of total billed charges,,,,,,,,,,,,,,,44.16,,,percent of total billed charges,,,,,,,,,40.84,,,percent of total billed charges,,,40.84,,,percent of total billed charges,,,,,,,,,110.39,,,percent of total billed charges,,,110.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,110.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.83,,,percent of total billed charges,,,110.39,,,percent of total billed charges,,,,,,,,,,,,,,,110.39,,,percent of total billed charges,,,110.39,,,percent of total billed charges,,,,,,,,,102.68,,,percent of total billed charges,,,,,,,,,,,,,,,102.68,,,percent of total billed charges,,,102.68,,,percent of total billed charges,,,102.68,,,percent of total billed charges,,,82.79,,,percent of total billed charges,,,110.39,,,percent of total billed charges,,,110.39,,,percent of total billed charges,,,110.39,,,percent of total billed charges,,,,,,,,,77.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,65.04,,,percent of total billed charges,,
BELLADONNA/OPIUM 60 MG SUP,2500007420,CDM,637,RC,999,EAPG,,,,,,outpatient,facility,1,UN,110.39,110.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENZOCAINE 20  SPR 0.5 ML,2500007466,CDM,637,RC,283061026,NDC,,,,,,inpatient,facility,1,UN,19.95,19.95,1.6,19.95,,,,,,,,,,,,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.95,,,percent of total billed charges,,,,,,,,,19.95,,,percent of total billed charges,,,10.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.97,,,percent of total billed charges,,,,,,,,,,,,,,,19.95,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,19.95,,,percent of total billed charges,,,10.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.75,,,percent of total billed charges,,
BENZOCAINE 20  SPR 0.5 ML,2500007466,CDM,637,RC,283061026,NDC,,,,,,outpatient,facility,1,UN,19.95,19.95,1.6,548.68,,14.15,,,percent of total billed charges,,,4.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,19.95,,,percent of total billed charges,,,12.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,14.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,14.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,19.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,19.95,,,fee schedule,,,19.95,,,percent of total billed charges,,,,,,,,,19.95,,,percent of total billed charges,,,12.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.21,,,percent of total billed charges,,,,,,,,,,,,,,,10.77,,,percent of total billed charges,,,10.37,,,percent of total billed charges,,,10.97,,,percent of total billed charges,,,,,,,,,11.77,,,percent of total billed charges,,,548.68,,,per diem,,,19.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,19.95,,,percent of total billed charges,,,16.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.6,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,16.14,,,percent of total billed charges,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,,,,,,,7.38,,,percent of total billed charges,,,7.38,,,percent of total billed charges,,,,,,,,,19.95,,,percent of total billed charges,,,19.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.6,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,19.95,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,18.56,,,percent of total billed charges,,,,,,,,,,,,,,,18.56,,,percent of total billed charges,,,18.56,,,percent of total billed charges,,,18.56,,,percent of total billed charges,,,14.96,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,13.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.75,,,percent of total billed charges,,
BENZOCAINE 20  SPR 0.5 ML,2500007466,CDM,637,RC,283061026,NDC,999,EAPG,,,,outpatient,facility,1,UN,19.95,19.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENZONATATE 100 MG CAP,2500007510,CDM,637,RC,904656461,NDC,,,,,,inpatient,facility,100,UN,1.61,1.61,0.13,1.61,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,
BENZONATATE 100 MG CAP,2500007510,CDM,637,RC,904656461,NDC,,,,,,outpatient,facility,100,UN,1.61,1.61,0.13,548.68,,1.14,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.61,,,percent of total billed charges,,,1.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.59,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.61,,,fee schedule,,,1.61,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,548.68,,,per diem,,,1.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.61,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,,,,,,,0.6,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.95,,,percent of total billed charges,,
BENZONATATE 100 MG CAP,2500007510,CDM,637,RC,904656461,NDC,999,EAPG,,,,outpatient,facility,100,UN,1.61,1.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENZTROPINE MESY 0.5 MG TAB,2500007530,CDM,637,RC,904678861,NDC,,,,,,inpatient,facility,0.5,UN,1.45,1.45,0.12,1.45,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,
BENZTROPINE MESY 0.5 MG TAB,2500007530,CDM,637,RC,904678861,NDC,,,,,,outpatient,facility,0.5,UN,1.45,1.45,0.12,548.68,,1.03,,,percent of total billed charges,,,0.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.45,,,percent of total billed charges,,,0.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.53,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.45,,,fee schedule,,,1.45,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,0.86,,,percent of total billed charges,,,548.68,,,per diem,,,1.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.45,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,0.54,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,1.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.85,,,percent of total billed charges,,
BENZTROPINE MESY 0.5 MG TAB,2500007530,CDM,637,RC,904678861,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,1.45,1.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENZTROPINE MESY 1 MG TAB,2500007532,CDM,637,RC,904679061,NDC,,,,,,inpatient,facility,1,UN,1.62,1.62,0.13,1.62,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,1.62,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,
BENZTROPINE MESY 1 MG TAB,2500007532,CDM,637,RC,904679061,NDC,,,,,,outpatient,facility,1,UN,1.62,1.62,0.13,548.68,,1.15,,,percent of total billed charges,,,0.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.62,,,percent of total billed charges,,,1.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.59,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.62,,,fee schedule,,,1.62,,,percent of total billed charges,,,,,,,,,1.62,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,0.96,,,percent of total billed charges,,,548.68,,,per diem,,,1.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.62,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,0.6,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,1.62,,,percent of total billed charges,,,1.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.95,,,percent of total billed charges,,
BENZTROPINE MESY 1 MG TAB,2500007532,CDM,637,RC,904679061,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.62,1.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BETAMETH DIP 0.05  CR 15 GM,2500007570,CDM,637,RC,7071012331,NDC,,,,,,inpatient,facility,15,UN,145.2,145.2,11.62,145.2,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,,,,,145.2,,,percent of total billed charges,,,74.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.12,,,percent of total billed charges,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,123.42,,,percent of total billed charges,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,77.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,,,,,,,,,,,11.62,,,percent of total billed charges,,,145.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.55,,,percent of total billed charges,,
BETAMETH DIP 0.05  CR 15 GM,2500007570,CDM,637,RC,7071012331,NDC,,,,,,outpatient,facility,15,UN,145.2,145.2,11.62,548.68,,102.96,,,percent of total billed charges,,,35.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,145.2,,,percent of total billed charges,,,91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,102.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,102.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,53.14,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,145.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,145.2,,,fee schedule,,,145.2,,,percent of total billed charges,,,,,,,,,145.2,,,percent of total billed charges,,,88.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.45,,,percent of total billed charges,,,,,,,,,,,,,,,78.41,,,percent of total billed charges,,,75.5,,,percent of total billed charges,,,79.86,,,percent of total billed charges,,,,,,,,,85.67,,,percent of total billed charges,,,548.68,,,per diem,,,145.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,145.2,,,percent of total billed charges,,,123.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.12,,,percent of total billed charges,,,145.2,,,percent of total billed charges,,,145.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.95,,,percent of total billed charges,,,117.5,,,percent of total billed charges,,,,,,,,,,,,,,,58.08,,,percent of total billed charges,,,,,,,,,53.72,,,percent of total billed charges,,,53.72,,,percent of total billed charges,,,,,,,,,145.2,,,percent of total billed charges,,,145.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,145.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.62,,,percent of total billed charges,,,145.2,,,percent of total billed charges,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,145.2,,,percent of total billed charges,,,,,,,,,135.07,,,percent of total billed charges,,,,,,,,,,,,,,,135.07,,,percent of total billed charges,,,135.07,,,percent of total billed charges,,,135.07,,,percent of total billed charges,,,108.9,,,percent of total billed charges,,,145.2,,,percent of total billed charges,,,145.2,,,percent of total billed charges,,,145.2,,,percent of total billed charges,,,,,,,,,101.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,85.55,,,percent of total billed charges,,
BETAMETH DIP 0.05  CR 15 GM,2500007570,CDM,637,RC,7071012331,NDC,999,EAPG,,,,outpatient,facility,15,UN,145.2,145.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BETAMETH DIP 0.05  LOT 20 ML,2500007573,CDM,637,RC,4580202146,NDC,,,,,,inpatient,facility,20,UN,49.5,49.5,3.96,49.5,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,25.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,42.08,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,26.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.17,,,percent of total billed charges,,
BETAMETH DIP 0.05  LOT 20 ML,2500007573,CDM,637,RC,4580202146,NDC,,,,,,outpatient,facility,20,UN,49.5,49.5,3.96,548.68,,35.1,,,percent of total billed charges,,,12.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,49.5,,,percent of total billed charges,,,31.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,34.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,34.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,18.12,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,49.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,49.5,,,fee schedule,,,49.5,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,30.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.27,,,percent of total billed charges,,,,,,,,,,,,,,,26.73,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,27.23,,,percent of total billed charges,,,,,,,,,29.2,,,percent of total billed charges,,,548.68,,,per diem,,,49.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,49.5,,,percent of total billed charges,,,42.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.29,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.39,,,percent of total billed charges,,,40.06,,,percent of total billed charges,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,18.32,,,percent of total billed charges,,,18.32,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,49.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,49.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.96,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,46.04,,,percent of total billed charges,,,,,,,,,,,,,,,46.04,,,percent of total billed charges,,,46.04,,,percent of total billed charges,,,46.04,,,percent of total billed charges,,,37.13,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,34.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,29.17,,,percent of total billed charges,,
BETAMETH DIP 0.05  LOT 20 ML,2500007573,CDM,637,RC,4580202146,NDC,999,EAPG,,,,outpatient,facility,20,UN,49.5,49.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BETAMETH DIP 0.05  OINT 15 GM,2500007577,CDM,637,RC,168005615,NDC,,,,,,inpatient,facility,15,UN,202.92,202.92,16.23,202.92,,,,,,,,,,,,,,202.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.92,,,percent of total billed charges,,,,,,,,,202.92,,,percent of total billed charges,,,103.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.75,,,percent of total billed charges,,,,,,,,,,,,,,,202.92,,,percent of total billed charges,,,172.48,,,percent of total billed charges,,,,,,,,,,,,,,,202.92,,,percent of total billed charges,,,107.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,202.92,,,percent of total billed charges,,,,,,,,,,,,,,,16.23,,,percent of total billed charges,,,202.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,202.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.56,,,percent of total billed charges,,
BETAMETH DIP 0.05  OINT 15 GM,2500007577,CDM,637,RC,168005615,NDC,,,,,,outpatient,facility,15,UN,202.92,202.92,16.23,548.68,,143.89,,,percent of total billed charges,,,49.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,202.92,,,percent of total billed charges,,,127.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,142.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,142.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,202.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,74.27,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,202.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,202.92,,,fee schedule,,,202.92,,,percent of total billed charges,,,,,,,,,202.92,,,percent of total billed charges,,,124.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.58,,,percent of total billed charges,,,,,,,,,,,,,,,109.58,,,percent of total billed charges,,,105.52,,,percent of total billed charges,,,111.61,,,percent of total billed charges,,,,,,,,,119.72,,,percent of total billed charges,,,548.68,,,per diem,,,202.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,202.92,,,percent of total billed charges,,,172.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,107.77,,,percent of total billed charges,,,202.92,,,percent of total billed charges,,,202.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.89,,,percent of total billed charges,,,164.2,,,percent of total billed charges,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,,,,,,,,75.08,,,percent of total billed charges,,,75.08,,,percent of total billed charges,,,,,,,,,202.92,,,percent of total billed charges,,,202.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,202.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.23,,,percent of total billed charges,,,202.92,,,percent of total billed charges,,,,,,,,,,,,,,,202.92,,,percent of total billed charges,,,202.92,,,percent of total billed charges,,,,,,,,,188.76,,,percent of total billed charges,,,,,,,,,,,,,,,188.76,,,percent of total billed charges,,,188.76,,,percent of total billed charges,,,188.76,,,percent of total billed charges,,,152.19,,,percent of total billed charges,,,202.92,,,percent of total billed charges,,,202.92,,,percent of total billed charges,,,202.92,,,percent of total billed charges,,,,,,,,,142.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,119.56,,,percent of total billed charges,,
BETAMETH DIP 0.05  OINT 15 GM,2500007577,CDM,637,RC,168005615,NDC,999,EAPG,,,,outpatient,facility,15,UN,202.92,202.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BETAMETH DIP AUG 0.05  OINT15G,2500007584,CDM,637,RC,168026850,NDC,,,,,,inpatient,facility,15,UN,184.24,184.24,14.74,184.24,,,,,,,,,,,,,,184.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.24,,,percent of total billed charges,,,,,,,,,184.24,,,percent of total billed charges,,,94.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.54,,,percent of total billed charges,,,,,,,,,,,,,,,184.24,,,percent of total billed charges,,,156.6,,,percent of total billed charges,,,,,,,,,,,,,,,184.24,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,184.24,,,percent of total billed charges,,,,,,,,,,,,,,,14.74,,,percent of total billed charges,,,184.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,184.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.55,,,percent of total billed charges,,
BETAMETH DIP AUG 0.05  OINT15G,2500007584,CDM,637,RC,168026850,NDC,,,,,,outpatient,facility,15,UN,184.24,184.24,14.74,548.68,,130.64,,,percent of total billed charges,,,44.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,184.24,,,percent of total billed charges,,,115.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,129.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,129.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,184.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,67.43,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,184.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,184.24,,,fee schedule,,,184.24,,,percent of total billed charges,,,,,,,,,184.24,,,percent of total billed charges,,,112.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.27,,,percent of total billed charges,,,,,,,,,,,,,,,99.49,,,percent of total billed charges,,,95.8,,,percent of total billed charges,,,101.33,,,percent of total billed charges,,,,,,,,,108.7,,,percent of total billed charges,,,548.68,,,per diem,,,184.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,184.24,,,percent of total billed charges,,,156.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,97.85,,,percent of total billed charges,,,184.24,,,percent of total billed charges,,,184.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.29,,,percent of total billed charges,,,149.09,,,percent of total billed charges,,,,,,,,,,,,,,,73.7,,,percent of total billed charges,,,,,,,,,68.17,,,percent of total billed charges,,,68.17,,,percent of total billed charges,,,,,,,,,184.24,,,percent of total billed charges,,,184.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,184.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.74,,,percent of total billed charges,,,184.24,,,percent of total billed charges,,,,,,,,,,,,,,,184.24,,,percent of total billed charges,,,184.24,,,percent of total billed charges,,,,,,,,,171.38,,,percent of total billed charges,,,,,,,,,,,,,,,171.38,,,percent of total billed charges,,,171.38,,,percent of total billed charges,,,171.38,,,percent of total billed charges,,,138.18,,,percent of total billed charges,,,184.24,,,percent of total billed charges,,,184.24,,,percent of total billed charges,,,184.24,,,percent of total billed charges,,,,,,,,,129.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,108.55,,,percent of total billed charges,,
BETAMETH DIP AUG 0.05  OINT15G,2500007584,CDM,637,RC,168026850,NDC,999,EAPG,,,,outpatient,facility,15,UN,184.24,184.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BETAMETH/CLOTRIMAZOLE CR 15GM,2500007602,CDM,637,RC,6846229817,NDC,,,,,,inpatient,facility,15,UN,185.46,185.46,14.84,185.46,,,,,,,,,,,,,,185.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.46,,,percent of total billed charges,,,,,,,,,185.46,,,percent of total billed charges,,,94.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.28,,,percent of total billed charges,,,,,,,,,,,,,,,185.46,,,percent of total billed charges,,,157.64,,,percent of total billed charges,,,,,,,,,,,,,,,185.46,,,percent of total billed charges,,,98.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,185.46,,,percent of total billed charges,,,,,,,,,,,,,,,14.84,,,percent of total billed charges,,,185.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,185.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.27,,,percent of total billed charges,,
BETAMETH/CLOTRIMAZOLE CR 15GM,2500007602,CDM,637,RC,6846229817,NDC,,,,,,outpatient,facility,15,UN,185.46,185.46,14.84,548.68,,131.51,,,percent of total billed charges,,,45.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,185.46,,,percent of total billed charges,,,116.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,130.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,130.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,185.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,67.88,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,185.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,185.46,,,fee schedule,,,185.46,,,percent of total billed charges,,,,,,,,,185.46,,,percent of total billed charges,,,113.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.14,,,percent of total billed charges,,,,,,,,,,,,,,,100.15,,,percent of total billed charges,,,96.44,,,percent of total billed charges,,,102,,,percent of total billed charges,,,,,,,,,109.42,,,percent of total billed charges,,,548.68,,,per diem,,,185.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,185.46,,,percent of total billed charges,,,157.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.5,,,percent of total billed charges,,,185.46,,,percent of total billed charges,,,185.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.11,,,percent of total billed charges,,,150.07,,,percent of total billed charges,,,,,,,,,,,,,,,74.18,,,percent of total billed charges,,,,,,,,,68.62,,,percent of total billed charges,,,68.62,,,percent of total billed charges,,,,,,,,,185.46,,,percent of total billed charges,,,185.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,185.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.84,,,percent of total billed charges,,,185.46,,,percent of total billed charges,,,,,,,,,,,,,,,185.46,,,percent of total billed charges,,,185.46,,,percent of total billed charges,,,,,,,,,172.51,,,percent of total billed charges,,,,,,,,,,,,,,,172.51,,,percent of total billed charges,,,172.51,,,percent of total billed charges,,,172.51,,,percent of total billed charges,,,139.09,,,percent of total billed charges,,,185.46,,,percent of total billed charges,,,185.46,,,percent of total billed charges,,,185.46,,,percent of total billed charges,,,,,,,,,130.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,109.27,,,percent of total billed charges,,
BETAMETH/CLOTRIMAZOLE CR 15GM,2500007602,CDM,637,RC,6846229817,NDC,999,EAPG,,,,outpatient,facility,15,UN,185.46,185.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BETHANECHOL CHL 25 MG TAB,2500007622,CDM,637,RC,832051201,NDC,,,,,,inpatient,facility,25,UN,8.81,8.81,0.7,8.81,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,8.81,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.29,,,percent of total billed charges,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.19,,,percent of total billed charges,,
BETHANECHOL CHL 25 MG TAB,2500007622,CDM,637,RC,832051201,NDC,,,,,,outpatient,facility,25,UN,8.81,8.81,0.7,548.68,,6.25,,,percent of total billed charges,,,2.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.81,,,percent of total billed charges,,,5.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.81,,,fee schedule,,,8.81,,,percent of total billed charges,,,,,,,,,8.81,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.28,,,percent of total billed charges,,,,,,,,,,,,,,,4.76,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,4.85,,,percent of total billed charges,,,,,,,,,5.2,,,percent of total billed charges,,,548.68,,,per diem,,,8.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.81,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,,,,,,,,3.26,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,,,,,,,8.81,,,percent of total billed charges,,,8.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.7,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,8.2,,,percent of total billed charges,,,,,,,,,,,,,,,8.2,,,percent of total billed charges,,,8.2,,,percent of total billed charges,,,8.2,,,percent of total billed charges,,,6.61,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,6.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.19,,,percent of total billed charges,,
BETHANECHOL CHL 25 MG TAB,2500007622,CDM,637,RC,832051201,NDC,999,EAPG,,,,outpatient,facility,25,UN,8.81,8.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BICALUTAMIDE 50 MG TAB,2500007630,CDM,637,RC,4733548583,NDC,,,,,,inpatient,facility,50,UN,61.15,61.15,4.89,61.15,,,,,,,,,,,,,,61.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.15,,,percent of total billed charges,,,,,,,,,61.15,,,percent of total billed charges,,,31.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.69,,,percent of total billed charges,,,,,,,,,,,,,,,61.15,,,percent of total billed charges,,,51.98,,,percent of total billed charges,,,,,,,,,,,,,,,61.15,,,percent of total billed charges,,,32.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,61.15,,,percent of total billed charges,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,61.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.03,,,percent of total billed charges,,
BICALUTAMIDE 50 MG TAB,2500007630,CDM,637,RC,4733548583,NDC,,,,,,outpatient,facility,50,UN,61.15,61.15,4.89,548.68,,43.36,,,percent of total billed charges,,,14.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,61.15,,,percent of total billed charges,,,38.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,42.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,42.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,61.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,22.38,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,61.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,61.15,,,fee schedule,,,61.15,,,percent of total billed charges,,,,,,,,,61.15,,,percent of total billed charges,,,37.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.57,,,percent of total billed charges,,,,,,,,,,,,,,,33.02,,,percent of total billed charges,,,31.8,,,percent of total billed charges,,,33.63,,,percent of total billed charges,,,,,,,,,36.08,,,percent of total billed charges,,,548.68,,,per diem,,,61.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,61.15,,,percent of total billed charges,,,51.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.48,,,percent of total billed charges,,,61.15,,,percent of total billed charges,,,61.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.25,,,percent of total billed charges,,,49.48,,,percent of total billed charges,,,,,,,,,,,,,,,24.46,,,percent of total billed charges,,,,,,,,,22.63,,,percent of total billed charges,,,22.63,,,percent of total billed charges,,,,,,,,,61.15,,,percent of total billed charges,,,61.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,61.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.89,,,percent of total billed charges,,,61.15,,,percent of total billed charges,,,,,,,,,,,,,,,61.15,,,percent of total billed charges,,,61.15,,,percent of total billed charges,,,,,,,,,56.88,,,percent of total billed charges,,,,,,,,,,,,,,,56.88,,,percent of total billed charges,,,56.88,,,percent of total billed charges,,,56.88,,,percent of total billed charges,,,45.86,,,percent of total billed charges,,,61.15,,,percent of total billed charges,,,61.15,,,percent of total billed charges,,,61.15,,,percent of total billed charges,,,,,,,,,42.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,36.03,,,percent of total billed charges,,
BICALUTAMIDE 50 MG TAB,2500007630,CDM,637,RC,4733548583,NDC,999,EAPG,,,,outpatient,facility,50,UN,61.15,61.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BISACODYL 10 MG SUPP,2500007660,CDM,637,RC,574705050,NDC,,,,,,inpatient,facility,10,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
BISACODYL 10 MG SUPP,2500007660,CDM,637,RC,574705050,NDC,,,,,,outpatient,facility,10,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
BISACODYL 10 MG SUPP,2500007660,CDM,637,RC,574705050,NDC,999,EAPG,,,,outpatient,facility,10,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BISACODYL 5 MG TABEC,2500007663,CDM,637,RC,904640761,NDC,,,,,,inpatient,facility,5,UN,1.94,1.94,0.16,1.94,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,
BISACODYL 5 MG TABEC,2500007663,CDM,637,RC,904640761,NDC,,,,,,outpatient,facility,5,UN,1.94,1.94,0.16,548.68,,1.38,,,percent of total billed charges,,,0.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.94,,,percent of total billed charges,,,1.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.94,,,fee schedule,,,1.94,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,1.14,,,percent of total billed charges,,,548.68,,,per diem,,,1.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.94,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,0.72,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.14,,,percent of total billed charges,,
BISACODYL 5 MG TABEC,2500007663,CDM,637,RC,904640761,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.94,1.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BISMUTH SUBSALICYLATE 30ML UDC,2500007678,CDM,637,RC,3700003204,NDC,,,,,,inpatient,facility,30,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
BISMUTH SUBSALICYLATE 30ML UDC,2500007678,CDM,637,RC,3700003204,NDC,,,,,,outpatient,facility,30,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
BISMUTH SUBSALICYLATE 30ML UDC,2500007678,CDM,637,RC,3700003204,NDC,999,EAPG,,,,outpatient,facility,30,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BRIMONIDINE TART OPH 0.2  5 ML,2500007740,CDM,637,RC,6131414305,NDC,,,,,,inpatient,facility,5,UN,107.75,107.75,8.62,107.75,,,,,,,,,,,,,,107.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.75,,,percent of total billed charges,,,,,,,,,107.75,,,percent of total billed charges,,,55.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.65,,,percent of total billed charges,,,,,,,,,,,,,,,107.75,,,percent of total billed charges,,,91.59,,,percent of total billed charges,,,,,,,,,,,,,,,107.75,,,percent of total billed charges,,,57.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,107.75,,,percent of total billed charges,,,,,,,,,,,,,,,8.62,,,percent of total billed charges,,,107.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,107.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.49,,,percent of total billed charges,,
BRIMONIDINE TART OPH 0.2  5 ML,2500007740,CDM,637,RC,6131414305,NDC,,,,,,outpatient,facility,5,UN,107.75,107.75,8.62,548.68,,76.41,,,percent of total billed charges,,,26.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,107.75,,,percent of total billed charges,,,67.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,75.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,75.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,107.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,39.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,107.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,107.75,,,fee schedule,,,107.75,,,percent of total billed charges,,,,,,,,,107.75,,,percent of total billed charges,,,66.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.77,,,percent of total billed charges,,,,,,,,,,,,,,,58.19,,,percent of total billed charges,,,56.03,,,percent of total billed charges,,,59.26,,,percent of total billed charges,,,,,,,,,63.57,,,percent of total billed charges,,,548.68,,,per diem,,,107.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,107.75,,,percent of total billed charges,,,91.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.23,,,percent of total billed charges,,,107.75,,,percent of total billed charges,,,107.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.69,,,percent of total billed charges,,,87.19,,,percent of total billed charges,,,,,,,,,,,,,,,43.1,,,percent of total billed charges,,,,,,,,,39.87,,,percent of total billed charges,,,39.87,,,percent of total billed charges,,,,,,,,,107.75,,,percent of total billed charges,,,107.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,107.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.62,,,percent of total billed charges,,,107.75,,,percent of total billed charges,,,,,,,,,,,,,,,107.75,,,percent of total billed charges,,,107.75,,,percent of total billed charges,,,,,,,,,100.23,,,percent of total billed charges,,,,,,,,,,,,,,,100.23,,,percent of total billed charges,,,100.23,,,percent of total billed charges,,,100.23,,,percent of total billed charges,,,80.81,,,percent of total billed charges,,,107.75,,,percent of total billed charges,,,107.75,,,percent of total billed charges,,,107.75,,,percent of total billed charges,,,,,,,,,75.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,63.49,,,percent of total billed charges,,
BRIMONIDINE TART OPH 0.2  5 ML,2500007740,CDM,637,RC,6131414305,NDC,999,EAPG,,,,outpatient,facility,5,UN,107.75,107.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BROMOCRIPTINE MESY 2.5 MG TAB,2500007760,CDM,637,RC,574010603,NDC,,,,,,inpatient,facility,2.5,UN,10.92,10.92,0.87,10.92,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,10.92,,,percent of total billed charges,,,5.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.55,,,percent of total billed charges,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,9.28,,,percent of total billed charges,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,
BROMOCRIPTINE MESY 2.5 MG TAB,2500007760,CDM,637,RC,574010603,NDC,,,,,,outpatient,facility,2.5,UN,10.92,10.92,0.87,548.68,,7.74,,,percent of total billed charges,,,2.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.92,,,percent of total billed charges,,,6.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.92,,,fee schedule,,,10.92,,,percent of total billed charges,,,,,,,,,10.92,,,percent of total billed charges,,,6.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.78,,,percent of total billed charges,,,,,,,,,,,,,,,5.9,,,percent of total billed charges,,,5.68,,,percent of total billed charges,,,6.01,,,percent of total billed charges,,,,,,,,,6.44,,,percent of total billed charges,,,548.68,,,per diem,,,10.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.92,,,percent of total billed charges,,,9.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.37,,,percent of total billed charges,,,8.84,,,percent of total billed charges,,,,,,,,,,,,,,,4.37,,,percent of total billed charges,,,,,,,,,4.04,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,10.92,,,percent of total billed charges,,,10.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.87,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,10.16,,,percent of total billed charges,,,,,,,,,,,,,,,10.16,,,percent of total billed charges,,,10.16,,,percent of total billed charges,,,10.16,,,percent of total billed charges,,,8.19,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.43,,,percent of total billed charges,,
BROMOCRIPTINE MESY 2.5 MG TAB,2500007760,CDM,637,RC,574010603,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,10.92,10.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUDESONIDE 3MG CAP,2500007787,CDM,637,RC,6516277810,NDC,,,,,,inpatient,facility,3,UN,82.04,82.04,6.56,82.04,,,,,,,,,,,,,,82.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.04,,,percent of total billed charges,,,,,,,,,82.04,,,percent of total billed charges,,,41.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.22,,,percent of total billed charges,,,,,,,,,,,,,,,82.04,,,percent of total billed charges,,,69.73,,,percent of total billed charges,,,,,,,,,,,,,,,82.04,,,percent of total billed charges,,,43.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,82.04,,,percent of total billed charges,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,82.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.34,,,percent of total billed charges,,
BUDESONIDE 3MG CAP,2500007787,CDM,637,RC,6516277810,NDC,,,,,,outpatient,facility,3,UN,82.04,82.04,6.56,548.68,,58.17,,,percent of total billed charges,,,20.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,82.04,,,percent of total billed charges,,,51.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,57.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,57.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,82.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,30.03,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,82.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,82.04,,,fee schedule,,,82.04,,,percent of total billed charges,,,,,,,,,82.04,,,percent of total billed charges,,,50.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.45,,,percent of total billed charges,,,,,,,,,,,,,,,44.3,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,45.12,,,percent of total billed charges,,,,,,,,,48.4,,,percent of total billed charges,,,548.68,,,per diem,,,82.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,82.04,,,percent of total billed charges,,,69.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.57,,,percent of total billed charges,,,82.04,,,percent of total billed charges,,,82.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.34,,,percent of total billed charges,,,66.39,,,percent of total billed charges,,,,,,,,,,,,,,,32.82,,,percent of total billed charges,,,,,,,,,30.35,,,percent of total billed charges,,,30.35,,,percent of total billed charges,,,,,,,,,82.04,,,percent of total billed charges,,,82.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,82.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.56,,,percent of total billed charges,,,82.04,,,percent of total billed charges,,,,,,,,,,,,,,,82.04,,,percent of total billed charges,,,82.04,,,percent of total billed charges,,,,,,,,,76.31,,,percent of total billed charges,,,,,,,,,,,,,,,76.31,,,percent of total billed charges,,,76.31,,,percent of total billed charges,,,76.31,,,percent of total billed charges,,,61.53,,,percent of total billed charges,,,82.04,,,percent of total billed charges,,,82.04,,,percent of total billed charges,,,82.04,,,percent of total billed charges,,,,,,,,,57.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,48.34,,,percent of total billed charges,,
BUDESONIDE 3MG CAP,2500007787,CDM,637,RC,6516277810,NDC,999,EAPG,,,,outpatient,facility,3,UN,82.04,82.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUMETANIDE 0.25 MG/ML 10ML INJ,2500007790,CDM,250,RC,J3490,HCPCS,641600710,NDC,,,,inpatient,facility,10,UN,10.82,10.82,0.87,10.82,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,,,,,,,10.82,,,percent of total billed charges,,,5.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.49,,,percent of total billed charges,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,9.2,,,percent of total billed charges,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,5.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.38,,,percent of total billed charges,,
BUMETANIDE 0.25 MG/ML 10ML INJ,2500007790,CDM,250,RC,J3490,HCPCS,641600710,NDC,,,,outpatient,facility,10,UN,10.82,10.82,0.87,548.68,,7.67,,,percent of total billed charges,,,2.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.82,,,percent of total billed charges,,,6.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.96,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,10.82,,,fee schedule,,,10.82,,,percent of total billed charges,,,,,,,,,10.82,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.71,,,percent of total billed charges,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,,,,,,,6.38,,,percent of total billed charges,,,548.68,,,per diem,,,10.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.82,,,percent of total billed charges,,,9.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.75,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.3,,,percent of total billed charges,,,8.76,,,percent of total billed charges,,,,,,,,,,,,,,,4.33,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10.82,,,percent of total billed charges,,,10.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.87,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,8.12,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.38,,,percent of total billed charges,,
BUMETANIDE 0.25 MG/ML 10ML INJ,2500007790,CDM,250,RC,J3490,HCPCS,641600710,NDC,435,EAPG,,outpatient,facility,10,UN,10.82,10.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUMETANIDE 0.25 MG/ML 4 ML INJ,2500007792,CDM,250,RC,J3490,HCPCS,409141204,NDC,,,,inpatient,facility,4,ML,7.03,7.03,0.56,7.03,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,7.03,,,percent of total billed charges,,,3.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,5.98,,,percent of total billed charges,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,3.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.14,,,percent of total billed charges,,
BUMETANIDE 0.25 MG/ML 4 ML INJ,2500007792,CDM,250,RC,J3490,HCPCS,409141204,NDC,,,,outpatient,facility,4,ML,7.03,7.03,0.56,548.68,,4.98,,,percent of total billed charges,,,1.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.03,,,percent of total billed charges,,,4.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,7.03,,,fee schedule,,,7.03,,,percent of total billed charges,,,,,,,,,7.03,,,percent of total billed charges,,,4.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,4.15,,,percent of total billed charges,,,548.68,,,per diem,,,7.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.03,,,percent of total billed charges,,,5.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.73,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.74,,,percent of total billed charges,,,5.69,,,percent of total billed charges,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7.03,,,percent of total billed charges,,,7.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,5.27,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,4.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.14,,,percent of total billed charges,,
BUMETANIDE 0.25 MG/ML 4 ML INJ,2500007792,CDM,250,RC,J3490,HCPCS,409141204,NDC,435,EAPG,,outpatient,facility,4,ML,7.03,7.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPRENORPHINE 2 MG SL TAB,2500007804,CDM,637,RC,J0571,HCPCS,54017613,NDC,,,,inpatient,facility,2,UN,13.66,13.66,1.09,13.66,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,,,,,,,13.66,,,percent of total billed charges,,,6.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,
BUPRENORPHINE 2 MG SL TAB,2500007804,CDM,637,RC,J0571,HCPCS,54017613,NDC,,,,outpatient,facility,2,UN,13.66,13.66,0.69,548.68,,9.69,,,percent of total billed charges,,,3.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.66,,,percent of total billed charges,,,1,,,fee schedule,,,0.95,,,fee schedule,,,,,,,,,0.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.66,,,fee schedule,,,13.66,,,percent of total billed charges,,,,,,,,,13.66,,,percent of total billed charges,,,8.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,fee schedule,,,0.69,,,fee schedule,,,0.69,,,fee schedule,,,,,,,,,8.06,,,percent of total billed charges,,,548.68,,,per diem,,,13.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.66,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,0.8,,,fee schedule,,,0.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.22,,,percent of total billed charges,,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,5.46,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13.66,,,percent of total billed charges,,,13.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.09,,,percent of total billed charges,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,10.25,,,percent of total billed charges,,,13.66,,,percent of total billed charges,,,13.66,,,percent of total billed charges,,,13.66,,,percent of total billed charges,,,,,,,,,9.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.05,,,percent of total billed charges,,
BUPRENORPHINE 2 MG SL TAB,2500007804,CDM,637,RC,J0571,HCPCS,54017613,NDC,435,EAPG,,outpatient,facility,2,UN,13.66,13.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPRENORPHINE 8 MG SL TAB,2500007805,CDM,637,RC,J0571,HCPCS,54017713,NDC,,,,inpatient,facility,8,UN,25.54,25.54,2.04,25.54,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,25.54,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.32,,,percent of total billed charges,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,21.71,,,percent of total billed charges,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,13.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.05,,,percent of total billed charges,,
BUPRENORPHINE 8 MG SL TAB,2500007805,CDM,637,RC,J0571,HCPCS,54017713,NDC,,,,outpatient,facility,8,UN,25.54,25.54,0.69,548.68,,18.11,,,percent of total billed charges,,,6.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,25.54,,,percent of total billed charges,,,1,,,fee schedule,,,0.95,,,fee schedule,,,,,,,,,0.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.35,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,25.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,25.54,,,fee schedule,,,25.54,,,percent of total billed charges,,,,,,,,,25.54,,,percent of total billed charges,,,15.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,fee schedule,,,0.69,,,fee schedule,,,0.69,,,fee schedule,,,,,,,,,15.07,,,percent of total billed charges,,,548.68,,,per diem,,,25.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,25.54,,,percent of total billed charges,,,21.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.56,,,percent of total billed charges,,,0.8,,,fee schedule,,,0.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.23,,,percent of total billed charges,,,20.67,,,percent of total billed charges,,,,,,,,,,,,,,,10.22,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,25.54,,,percent of total billed charges,,,25.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.04,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,19.16,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,17.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15.05,,,percent of total billed charges,,
BUPRENORPHINE 8 MG SL TAB,2500007805,CDM,637,RC,J0571,HCPCS,54017713,NDC,435,EAPG,,outpatient,facility,8,UN,25.54,25.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPRENORPHIN/NALOX 2-0.5MG SL,2500007808,CDM,636,RC,J0572,HCPCS,54018813,NDC,,,,inpatient,facility,1,UN,19.24,19.24,1.54,19.24,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,19.24,,,percent of total billed charges,,,9.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.54,,,percent of total billed charges,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,16.35,,,percent of total billed charges,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,10.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.34,,,percent of total billed charges,,
BUPRENORPHIN/NALOX 2-0.5MG SL,2500007808,CDM,636,RC,J0572,HCPCS,54018813,NDC,,,,outpatient,facility,1,UN,19.24,19.24,1.54,548.68,,13.64,,,percent of total billed charges,,,4.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,19.24,,,percent of total billed charges,,,5.8,,,fee schedule,,,5.49,,,fee schedule,,,,,,,,,5.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.04,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,19.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,19.24,,,fee schedule,,,19.24,,,percent of total billed charges,,,,,,,,,19.24,,,percent of total billed charges,,,11.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.71,,,percent of total billed charges,,,,,,,,,,,,,,,4,,,fee schedule,,,4,,,fee schedule,,,4,,,fee schedule,,,,,,,,,11.35,,,percent of total billed charges,,,548.68,,,per diem,,,19.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,19.24,,,percent of total billed charges,,,16.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.22,,,percent of total billed charges,,,4.34,,,fee schedule,,,4.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.98,,,percent of total billed charges,,,15.57,,,percent of total billed charges,,,,,,,,,,,,,,,7.7,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,19.24,,,percent of total billed charges,,,19.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.54,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,14.43,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,,,,,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.62,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.34,,,percent of total billed charges,,
BUPRENORPHIN/NALOX 2-0.5MG SL,2500007808,CDM,636,RC,J0572,HCPCS,54018813,NDC,435,EAPG,,outpatient,facility,1,UN,19.24,19.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPRENORPHIN/NALOX 8-2 MG SL,2500007809,CDM,636,RC,J0574,HCPCS,904701006,NDC,,,,inpatient,facility,1,UN,13.16,13.16,1.05,13.16,,,,,,,,,,,,,,13.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.16,,,percent of total billed charges,,,,,,,,,13.16,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.9,,,percent of total billed charges,,,,,,,,,,,,,,,13.16,,,percent of total billed charges,,,11.19,,,percent of total billed charges,,,,,,,,,,,,,,,13.16,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.16,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,13.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.75,,,percent of total billed charges,,
BUPRENORPHIN/NALOX 8-2 MG SL,2500007809,CDM,636,RC,J0574,HCPCS,904701006,NDC,,,,outpatient,facility,1,UN,13.16,13.16,1.05,548.68,,9.33,,,percent of total billed charges,,,3.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.16,,,percent of total billed charges,,,11.47,,,fee schedule,,,10.86,,,fee schedule,,,,,,,,,10.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,13.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.82,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.16,,,fee schedule,,,13.16,,,percent of total billed charges,,,,,,,,,13.16,,,percent of total billed charges,,,8.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.38,,,percent of total billed charges,,,,,,,,,,,,,,,7.91,,,fee schedule,,,7.91,,,fee schedule,,,7.91,,,fee schedule,,,,,,,,,7.76,,,percent of total billed charges,,,548.68,,,per diem,,,13.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.16,,,percent of total billed charges,,,11.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.99,,,percent of total billed charges,,,13.16,,,percent of total billed charges,,,13.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.88,,,percent of total billed charges,,,10.65,,,percent of total billed charges,,,,,,,,,,,,,,,5.26,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13.16,,,percent of total billed charges,,,13.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.05,,,percent of total billed charges,,,13.16,,,percent of total billed charges,,,,,,,,,,,,,,,13.16,,,percent of total billed charges,,,13.16,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,9.87,,,percent of total billed charges,,,13.16,,,percent of total billed charges,,,13.16,,,percent of total billed charges,,,13.16,,,percent of total billed charges,,,,,,,,,9.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.75,,,percent of total billed charges,,
BUPRENORPHIN/NALOX 8-2 MG SL,2500007809,CDM,636,RC,J0574,HCPCS,904701006,NDC,435,EAPG,,outpatient,facility,1,UN,13.16,13.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPROPION 75 MG TAB,2500007810,CDM,637,RC,6050501581,NDC,,,,,,inpatient,facility,75,UN,2.6,2.6,0.21,2.6,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,,,,,,,2.6,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,
BUPROPION 75 MG TAB,2500007810,CDM,637,RC,6050501581,NDC,,,,,,outpatient,facility,75,UN,2.6,2.6,0.21,548.68,,1.84,,,percent of total billed charges,,,0.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.6,,,percent of total billed charges,,,1.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.95,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.6,,,fee schedule,,,2.6,,,percent of total billed charges,,,,,,,,,2.6,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,1.53,,,percent of total billed charges,,,548.68,,,per diem,,,2.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.6,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,2.1,,,percent of total billed charges,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,0.96,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,2.6,,,percent of total billed charges,,,2.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,,,,,,,2.42,,,percent of total billed charges,,,,,,,,,,,,,,,2.42,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.53,,,percent of total billed charges,,
BUPROPION 75 MG TAB,2500007810,CDM,637,RC,6050501581,NDC,999,EAPG,,,,outpatient,facility,75,UN,2.6,2.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPROPION HCL 100 MG TAB,2500007813,CDM,637,RC,6050501571,NDC,,,,,,inpatient,facility,100,UN,3.5,3.5,0.28,3.5,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,3.5,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.1,,,percent of total billed charges,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,
BUPROPION HCL 100 MG TAB,2500007813,CDM,637,RC,6050501571,NDC,,,,,,outpatient,facility,100,UN,3.5,3.5,0.28,548.68,,2.48,,,percent of total billed charges,,,0.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.5,,,percent of total billed charges,,,2.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.28,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.5,,,fee schedule,,,3.5,,,percent of total billed charges,,,,,,,,,3.5,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,,,,,,,2.06,,,percent of total billed charges,,,548.68,,,per diem,,,3.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.5,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,2.83,,,percent of total billed charges,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,3.5,,,percent of total billed charges,,,3.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,2.63,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,2.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.06,,,percent of total billed charges,,
BUPROPION HCL 100 MG TAB,2500007813,CDM,637,RC,6050501571,NDC,999,EAPG,,,,outpatient,facility,100,UN,3.5,3.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPROPION HCL 100 MG TABCR,2500007814,CDM,637,RC,6808469701,NDC,,,,,,inpatient,facility,100,UN,5.48,5.48,0.44,5.48,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,5.48,,,percent of total billed charges,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.29,,,percent of total billed charges,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,4.66,,,percent of total billed charges,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,
BUPROPION HCL 100 MG TABCR,2500007814,CDM,637,RC,6808469701,NDC,,,,,,outpatient,facility,100,UN,5.48,5.48,0.44,548.68,,3.89,,,percent of total billed charges,,,1.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.48,,,percent of total billed charges,,,3.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.48,,,fee schedule,,,5.48,,,percent of total billed charges,,,,,,,,,5.48,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.96,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,3.01,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,548.68,,,per diem,,,5.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.48,,,percent of total billed charges,,,4.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,4.43,,,percent of total billed charges,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,5.48,,,percent of total billed charges,,,5.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.44,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,5.1,,,percent of total billed charges,,,,,,,,,,,,,,,5.1,,,percent of total billed charges,,,5.1,,,percent of total billed charges,,,5.1,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,3.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.23,,,percent of total billed charges,,
BUPROPION HCL 100 MG TABCR,2500007814,CDM,637,RC,6808469701,NDC,999,EAPG,,,,outpatient,facility,100,UN,5.48,5.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPROPION HCL 150 MG TABCR,2500007815,CDM,637,RC,904658561,NDC,,,,,,inpatient,facility,150,UN,1.95,1.95,0.16,1.95,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,1.95,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,
BUPROPION HCL 150 MG TABCR,2500007815,CDM,637,RC,904658561,NDC,,,,,,outpatient,facility,150,UN,1.95,1.95,0.16,548.68,,1.38,,,percent of total billed charges,,,0.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.95,,,percent of total billed charges,,,1.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.95,,,fee schedule,,,1.95,,,percent of total billed charges,,,,,,,,,1.95,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,1.15,,,percent of total billed charges,,,548.68,,,per diem,,,1.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.95,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,0.72,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,1.95,,,percent of total billed charges,,,1.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.15,,,percent of total billed charges,,
BUPROPION HCL 150 MG TABCR,2500007815,CDM,637,RC,904658561,NDC,999,EAPG,,,,outpatient,facility,150,UN,1.95,1.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPROPION HCL 300 MG TABCR,2500007816,CDM,637,RC,6818032002,NDC,,,,,,inpatient,facility,300,UN,15.74,15.74,1.26,15.74,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,,,,,,,15.74,,,percent of total billed charges,,,8.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,13.38,,,percent of total billed charges,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,8.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.27,,,percent of total billed charges,,
BUPROPION HCL 300 MG TABCR,2500007816,CDM,637,RC,6818032002,NDC,,,,,,outpatient,facility,300,UN,15.74,15.74,1.26,548.68,,11.16,,,percent of total billed charges,,,3.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,15.74,,,percent of total billed charges,,,9.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,11.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,11.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.76,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,15.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,15.74,,,fee schedule,,,15.74,,,percent of total billed charges,,,,,,,,,15.74,,,percent of total billed charges,,,9.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.21,,,percent of total billed charges,,,,,,,,,,,,,,,8.5,,,percent of total billed charges,,,8.18,,,percent of total billed charges,,,8.66,,,percent of total billed charges,,,,,,,,,9.29,,,percent of total billed charges,,,548.68,,,per diem,,,15.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,15.74,,,percent of total billed charges,,,13.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.36,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.62,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,,6.3,,,percent of total billed charges,,,,,,,,,5.82,,,percent of total billed charges,,,5.82,,,percent of total billed charges,,,,,,,,,15.74,,,percent of total billed charges,,,15.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.26,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,,,,,,,14.64,,,percent of total billed charges,,,,,,,,,,,,,,,14.64,,,percent of total billed charges,,,14.64,,,percent of total billed charges,,,14.64,,,percent of total billed charges,,,11.8,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,,,,,,,11.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.27,,,percent of total billed charges,,
BUPROPION HCL 300 MG TABCR,2500007816,CDM,637,RC,6818032002,NDC,999,EAPG,,,,outpatient,facility,300,UN,15.74,15.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPROPION HCL 150 MG TAB XL,2500007817,CDM,637,RC,6818031906,NDC,,,,,,inpatient,facility,150,UN,15.74,15.74,1.26,15.74,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,,,,,,,15.74,,,percent of total billed charges,,,8.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,13.38,,,percent of total billed charges,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,8.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.27,,,percent of total billed charges,,
BUPROPION HCL 150 MG TAB XL,2500007817,CDM,637,RC,6818031906,NDC,,,,,,outpatient,facility,150,UN,15.74,15.74,1.26,548.68,,11.16,,,percent of total billed charges,,,3.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,15.74,,,percent of total billed charges,,,9.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,11.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,11.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.76,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,15.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,15.74,,,fee schedule,,,15.74,,,percent of total billed charges,,,,,,,,,15.74,,,percent of total billed charges,,,9.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.21,,,percent of total billed charges,,,,,,,,,,,,,,,8.5,,,percent of total billed charges,,,8.18,,,percent of total billed charges,,,8.66,,,percent of total billed charges,,,,,,,,,9.29,,,percent of total billed charges,,,548.68,,,per diem,,,15.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,15.74,,,percent of total billed charges,,,13.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.36,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.62,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,,6.3,,,percent of total billed charges,,,,,,,,,5.82,,,percent of total billed charges,,,5.82,,,percent of total billed charges,,,,,,,,,15.74,,,percent of total billed charges,,,15.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.26,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,,,,,,,14.64,,,percent of total billed charges,,,,,,,,,,,,,,,14.64,,,percent of total billed charges,,,14.64,,,percent of total billed charges,,,14.64,,,percent of total billed charges,,,11.8,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,,,,,,,11.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.27,,,percent of total billed charges,,
BUPROPION HCL 150 MG TAB XL,2500007817,CDM,637,RC,6818031906,NDC,999,EAPG,,,,outpatient,facility,150,UN,15.74,15.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUSPIRONE HCL 5 MG TAB,2500007833,CDM,637,RC,5107998520,NDC,,,,,,inpatient,facility,5,UN,2.54,2.54,0.2,2.54,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,2.54,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,
BUSPIRONE HCL 5 MG TAB,2500007833,CDM,637,RC,5107998520,NDC,,,,,,outpatient,facility,5,UN,2.54,2.54,0.2,548.68,,1.8,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.54,,,percent of total billed charges,,,1.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.93,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.54,,,fee schedule,,,2.54,,,percent of total billed charges,,,,,,,,,2.54,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,,,,,,,1.5,,,percent of total billed charges,,,548.68,,,per diem,,,2.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.54,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,0.94,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,,,,,,,2.54,,,percent of total billed charges,,,2.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.5,,,percent of total billed charges,,
BUSPIRONE HCL 5 MG TAB,2500007833,CDM,637,RC,5107998520,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.54,2.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAFFEINE CITRATE 60 MG INJ,2500007854,CDM,636,RC,J0706,HCPCS,641616410,NDC,,,,inpatient,facility,3,UN,33,33,2.64,33,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,16.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,17.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.44,,,percent of total billed charges,,
CAFFEINE CITRATE 60 MG INJ,2500007854,CDM,636,RC,J0706,HCPCS,641616410,NDC,,,,outpatient,facility,3,UN,33,33,2.64,548.68,,23.4,,,percent of total billed charges,,,8.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,33,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,33,,,fee schedule,,,33,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,20.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,19.47,,,percent of total billed charges,,,548.68,,,per diem,,,33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,33,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.53,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.26,,,percent of total billed charges,,,26.7,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,33,,,percent of total billed charges,,,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.64,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.83,,,fee schedule,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,23.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,19.44,,,percent of total billed charges,,
CAFFEINE CITRATE 60 MG INJ,2500007854,CDM,636,RC,J0706,HCPCS,641616410,NDC,496,EAPG,,outpatient,facility,3,UN,33,33,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAFFEINE CITRATE 60MG/3ML ORAL,2500007856,CDM,637,RC,7248511010,NDC,,,,,,inpatient,facility,3,UN,78.8,78.8,6.3,78.8,,,,,,,,,,,,,,78.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.8,,,percent of total billed charges,,,,,,,,,78.8,,,percent of total billed charges,,,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.28,,,percent of total billed charges,,,,,,,,,,,,,,,78.8,,,percent of total billed charges,,,66.98,,,percent of total billed charges,,,,,,,,,,,,,,,78.8,,,percent of total billed charges,,,41.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,78.8,,,percent of total billed charges,,,,,,,,,,,,,,,6.3,,,percent of total billed charges,,,78.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,78.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.43,,,percent of total billed charges,,
CAFFEINE CITRATE 60MG/3ML ORAL,2500007856,CDM,637,RC,7248511010,NDC,,,,,,outpatient,facility,3,UN,78.8,78.8,6.3,548.68,,55.88,,,percent of total billed charges,,,19.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,78.8,,,percent of total billed charges,,,49.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,55.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,55.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,78.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,28.84,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,78.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,78.8,,,fee schedule,,,78.8,,,percent of total billed charges,,,,,,,,,78.8,,,percent of total billed charges,,,48.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.15,,,percent of total billed charges,,,,,,,,,,,,,,,42.55,,,percent of total billed charges,,,40.98,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,,,,,,,46.49,,,percent of total billed charges,,,548.68,,,per diem,,,78.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,78.8,,,percent of total billed charges,,,66.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.85,,,percent of total billed charges,,,78.8,,,percent of total billed charges,,,78.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.16,,,percent of total billed charges,,,63.76,,,percent of total billed charges,,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,,,,,,,29.16,,,percent of total billed charges,,,29.16,,,percent of total billed charges,,,,,,,,,78.8,,,percent of total billed charges,,,78.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,78.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.3,,,percent of total billed charges,,,78.8,,,percent of total billed charges,,,,,,,,,,,,,,,78.8,,,percent of total billed charges,,,78.8,,,percent of total billed charges,,,,,,,,,73.3,,,percent of total billed charges,,,,,,,,,,,,,,,73.3,,,percent of total billed charges,,,73.3,,,percent of total billed charges,,,73.3,,,percent of total billed charges,,,59.1,,,percent of total billed charges,,,78.8,,,percent of total billed charges,,,78.8,,,percent of total billed charges,,,78.8,,,percent of total billed charges,,,,,,,,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,46.43,,,percent of total billed charges,,
CAFFEINE CITRATE 60MG/3ML ORAL,2500007856,CDM,637,RC,7248511010,NDC,999,EAPG,,,,outpatient,facility,3,UN,78.8,78.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALAMINE LOTION 180 ML,2500007881,CDM,637,RC,904253321,NDC,,,,,,inpatient,facility,180,UN,2.28,2.28,0.18,2.28,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,2.28,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,
CALAMINE LOTION 180 ML,2500007881,CDM,637,RC,904253321,NDC,,,,,,outpatient,facility,180,UN,2.28,2.28,0.18,548.68,,1.62,,,percent of total billed charges,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.28,,,percent of total billed charges,,,1.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.83,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.28,,,fee schedule,,,2.28,,,percent of total billed charges,,,,,,,,,2.28,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,548.68,,,per diem,,,2.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.28,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,,,,,,,0.84,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,2.28,,,percent of total billed charges,,,2.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.34,,,percent of total billed charges,,
CALAMINE LOTION 180 ML,2500007881,CDM,637,RC,904253321,NDC,999,EAPG,,,,outpatient,facility,180,UN,2.28,2.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALAMINE3 /PRAMOXINE 1 28GM CR,2500007885,CDM,637,RC,8137003690,NDC,,,,,,inpatient,facility,28,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
CALAMINE3 /PRAMOXINE 1 28GM CR,2500007885,CDM,637,RC,8137003690,NDC,,,,,,outpatient,facility,28,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
CALAMINE3 /PRAMOXINE 1 28GM CR,2500007885,CDM,637,RC,8137003690,NDC,999,EAPG,,,,outpatient,facility,28,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCIPOTRIENE 0.005  OINT 60 G,2500007916,CDM,637,RC,6699387761,NDC,,,,,,inpatient,facility,60,UN,1398.18,1398.18,111.85,1398.18,,,,,,,,,,,,,,1398.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.18,,,percent of total billed charges,,,,,,,,,1398.18,,,percent of total billed charges,,,713.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1190.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,838.91,,,percent of total billed charges,,,,,,,,,,,,,,,1398.18,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,,,,,,,,,,,,,1398.18,,,percent of total billed charges,,,742.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,559.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1398.18,,,percent of total billed charges,,,,,,,,,,,,,,,111.85,,,percent of total billed charges,,,1398.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1398.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,823.81,,,percent of total billed charges,,
CALCIPOTRIENE 0.005  OINT 60 G,2500007916,CDM,637,RC,6699387761,NDC,,,,,,outpatient,facility,60,UN,1398.18,1398.18,111.85,1398.18,,991.45,,,percent of total billed charges,,,341.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1398.18,,,percent of total billed charges,,,876.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,982.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,982.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1398.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,511.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1398.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1398.18,,,fee schedule,,,1398.18,,,percent of total billed charges,,,,,,,,,1398.18,,,percent of total billed charges,,,856.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,996.2,,,percent of total billed charges,,,,,,,,,,,,,,,755.02,,,percent of total billed charges,,,727.05,,,percent of total billed charges,,,769,,,percent of total billed charges,,,,,,,,,824.93,,,percent of total billed charges,,,548.68,,,per diem,,,1398.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1398.18,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,742.57,,,percent of total billed charges,,,1398.18,,,percent of total billed charges,,,1398.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,943.21,,,percent of total billed charges,,,1131.41,,,percent of total billed charges,,,,,,,,,,,,,,,559.27,,,percent of total billed charges,,,,,,,,,517.33,,,percent of total billed charges,,,517.33,,,percent of total billed charges,,,,,,,,,1398.18,,,percent of total billed charges,,,1398.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1398.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,111.85,,,percent of total billed charges,,,1398.18,,,percent of total billed charges,,,,,,,,,,,,,,,1398.18,,,percent of total billed charges,,,1398.18,,,percent of total billed charges,,,,,,,,,1300.59,,,percent of total billed charges,,,,,,,,,,,,,,,1300.59,,,percent of total billed charges,,,1300.59,,,percent of total billed charges,,,1300.59,,,percent of total billed charges,,,1048.63,,,percent of total billed charges,,,1398.18,,,percent of total billed charges,,,1398.18,,,percent of total billed charges,,,1398.18,,,percent of total billed charges,,,,,,,,,980.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,699.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,823.81,,,percent of total billed charges,,
CALCIPOTRIENE 0.005  OINT 60 G,2500007916,CDM,637,RC,6699387761,NDC,999,EAPG,,,,outpatient,facility,60,UN,1398.18,1398.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCITRIOL 0.25 MCG CAP,2500007930,CDM,637,RC,2315566201,NDC,,,,,,inpatient,facility,0.25,UN,3.99,3.99,0.32,3.99,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,
CALCITRIOL 0.25 MCG CAP,2500007930,CDM,637,RC,2315566201,NDC,,,,,,outpatient,facility,0.25,UN,3.99,3.99,0.32,548.68,,2.83,,,percent of total billed charges,,,0.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.99,,,percent of total billed charges,,,2.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.99,,,fee schedule,,,3.99,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,2.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,2.35,,,percent of total billed charges,,,548.68,,,per diem,,,3.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.99,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.69,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,1.48,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,3.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.32,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,3.71,,,percent of total billed charges,,,,,,,,,,,,,,,3.71,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.35,,,percent of total billed charges,,
CALCITRIOL 0.25 MCG CAP,2500007930,CDM,637,RC,2315566201,NDC,999,EAPG,,,,outpatient,facility,0.25,UN,3.99,3.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCITRIOL 0.5 MCG CAP,2500007932,CDM,637,RC,6945220820,NDC,,,,,,inpatient,facility,0.5,UN,7.97,7.97,0.64,7.97,,,,,,,,,,,,,,7.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.97,,,percent of total billed charges,,,,,,,,,7.97,,,percent of total billed charges,,,4.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,7.97,,,percent of total billed charges,,,6.77,,,percent of total billed charges,,,,,,,,,,,,,,,7.97,,,percent of total billed charges,,,4.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.97,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,7.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.7,,,percent of total billed charges,,
CALCITRIOL 0.5 MCG CAP,2500007932,CDM,637,RC,6945220820,NDC,,,,,,outpatient,facility,0.5,UN,7.97,7.97,0.64,548.68,,5.65,,,percent of total billed charges,,,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.97,,,percent of total billed charges,,,4.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.92,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.97,,,fee schedule,,,7.97,,,percent of total billed charges,,,,,,,,,7.97,,,percent of total billed charges,,,4.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.68,,,percent of total billed charges,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,,4.14,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,,,,,,,4.7,,,percent of total billed charges,,,548.68,,,per diem,,,7.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.97,,,percent of total billed charges,,,6.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.23,,,percent of total billed charges,,,7.97,,,percent of total billed charges,,,7.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.38,,,percent of total billed charges,,,6.45,,,percent of total billed charges,,,,,,,,,,,,,,,3.19,,,percent of total billed charges,,,,,,,,,2.95,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,,,,,,,7.97,,,percent of total billed charges,,,7.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.64,,,percent of total billed charges,,,7.97,,,percent of total billed charges,,,,,,,,,,,,,,,7.97,,,percent of total billed charges,,,7.97,,,percent of total billed charges,,,,,,,,,7.41,,,percent of total billed charges,,,,,,,,,,,,,,,7.41,,,percent of total billed charges,,,7.41,,,percent of total billed charges,,,7.41,,,percent of total billed charges,,,5.98,,,percent of total billed charges,,,7.97,,,percent of total billed charges,,,7.97,,,percent of total billed charges,,,7.97,,,percent of total billed charges,,,,,,,,,5.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.7,,,percent of total billed charges,,
CALCITRIOL 0.5 MCG CAP,2500007932,CDM,637,RC,6945220820,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,7.97,7.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCIUM ACETATE 667 MG TAB,2500007940,CDM,637,RC,781208102,NDC,,,,,,inpatient,facility,667,UN,2.6,2.6,0.21,2.6,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,,,,,,,2.6,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,
CALCIUM ACETATE 667 MG TAB,2500007940,CDM,637,RC,781208102,NDC,,,,,,outpatient,facility,667,UN,2.6,2.6,0.21,548.68,,1.84,,,percent of total billed charges,,,0.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.6,,,percent of total billed charges,,,1.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.95,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.6,,,fee schedule,,,2.6,,,percent of total billed charges,,,,,,,,,2.6,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,1.53,,,percent of total billed charges,,,548.68,,,per diem,,,2.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.6,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,2.1,,,percent of total billed charges,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,0.96,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,2.6,,,percent of total billed charges,,,2.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,,,,,,,2.42,,,percent of total billed charges,,,,,,,,,,,,,,,2.42,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.53,,,percent of total billed charges,,
CALCIUM ACETATE 667 MG TAB,2500007940,CDM,637,RC,781208102,NDC,999,EAPG,,,,outpatient,facility,667,UN,2.6,2.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCIUM CARB 500 MG CHEW TAB,2500007950,CDM,637,RC,6655300401,NDC,,,,,,inpatient,facility,500,UN,1.36,1.36,0.11,1.36,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,,,,,,,1.36,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,
CALCIUM CARB 500 MG CHEW TAB,2500007950,CDM,637,RC,6655300401,NDC,,,,,,outpatient,facility,500,UN,1.36,1.36,0.11,548.68,,0.96,,,percent of total billed charges,,,0.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.36,,,percent of total billed charges,,,0.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.5,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.36,,,fee schedule,,,1.36,,,percent of total billed charges,,,,,,,,,1.36,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,0.8,,,percent of total billed charges,,,548.68,,,per diem,,,1.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.36,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,1.36,,,percent of total billed charges,,,1.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.8,,,percent of total billed charges,,
CALCIUM CARB 500 MG CHEW TAB,2500007950,CDM,637,RC,6655300401,NDC,999,EAPG,,,,outpatient,facility,500,UN,1.36,1.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CALCIUM CL 10  10ML SYR INJ,2500007960,CDM,250,RC,J3490,HCPCS,7632933041,NDC,,,,inpatient,facility,10,UN,29.7,29.7,2.38,29.7,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,29.7,,,percent of total billed charges,,,15.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,25.24,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,15.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.5,,,percent of total billed charges,,
CALCIUM CL 10  10ML SYR INJ,2500007960,CDM,250,RC,J3490,HCPCS,7632933041,NDC,,,,outpatient,facility,10,UN,29.7,29.7,1.2,548.68,,21.06,,,percent of total billed charges,,,7.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,29.7,,,percent of total billed charges,,,18.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,20.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,20.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,29.7,,,fee schedule,,,29.7,,,percent of total billed charges,,,,,,,,,29.7,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.16,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,17.52,,,percent of total billed charges,,,548.68,,,per diem,,,29.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,29.7,,,percent of total billed charges,,,25.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.77,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.04,,,percent of total billed charges,,,24.03,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,29.7,,,percent of total billed charges,,,29.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.38,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,22.27,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,,,,,,,20.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.5,,,percent of total billed charges,,
CALCIUM CL 10  10ML SYR INJ,2500007960,CDM,250,RC,J3490,HCPCS,7632933041,NDC,435,EAPG,,outpatient,facility,10,UN,29.7,29.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAMPHOR/MENTHOL/PHENOL 225 ML,2500008060,CDM,637,RC,536126812,NDC,,,,,,inpatient,facility,225,UN,7.86,7.86,0.63,7.86,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,,,,,,,7.86,,,percent of total billed charges,,,4.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,6.68,,,percent of total billed charges,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,4.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,
CAMPHOR/MENTHOL/PHENOL 225 ML,2500008060,CDM,637,RC,536126812,NDC,,,,,,outpatient,facility,225,UN,7.86,7.86,0.63,548.68,,5.57,,,percent of total billed charges,,,1.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.86,,,percent of total billed charges,,,4.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.88,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.86,,,fee schedule,,,7.86,,,percent of total billed charges,,,,,,,,,7.86,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.6,,,percent of total billed charges,,,,,,,,,,,,,,,4.24,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,4.64,,,percent of total billed charges,,,548.68,,,per diem,,,7.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.86,,,percent of total billed charges,,,6.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.17,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.3,,,percent of total billed charges,,,6.36,,,percent of total billed charges,,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,,,,,,,2.91,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,7.86,,,percent of total billed charges,,,7.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.63,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,,,,,,,7.31,,,percent of total billed charges,,,,,,,,,,,,,,,7.31,,,percent of total billed charges,,,7.31,,,percent of total billed charges,,,7.31,,,percent of total billed charges,,,5.9,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.63,,,percent of total billed charges,,
CAMPHOR/MENTHOL/PHENOL 225 ML,2500008060,CDM,637,RC,536126812,NDC,999,EAPG,,,,outpatient,facility,225,UN,7.86,7.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAPSAICIN HP 0.075  CR 30 GM,2500008106,CDM,637,RC,536111825,NDC,,,,,,inpatient,facility,60,UN,16.3,16.3,1.3,16.3,,,,,,,,,,,,,,16.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.3,,,percent of total billed charges,,,,,,,,,16.3,,,percent of total billed charges,,,8.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,,,,,,,,,,,,,,16.3,,,percent of total billed charges,,,13.86,,,percent of total billed charges,,,,,,,,,,,,,,,16.3,,,percent of total billed charges,,,8.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,16.3,,,percent of total billed charges,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,16.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.6,,,percent of total billed charges,,
CAPSAICIN HP 0.075  CR 30 GM,2500008106,CDM,637,RC,536111825,NDC,,,,,,outpatient,facility,60,UN,16.3,16.3,1.3,548.68,,11.56,,,percent of total billed charges,,,3.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,16.3,,,percent of total billed charges,,,10.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,11.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,11.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.97,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,16.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,16.3,,,fee schedule,,,16.3,,,percent of total billed charges,,,,,,,,,16.3,,,percent of total billed charges,,,9.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,8.8,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,8.97,,,percent of total billed charges,,,,,,,,,9.62,,,percent of total billed charges,,,548.68,,,per diem,,,16.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,16.3,,,percent of total billed charges,,,13.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.66,,,percent of total billed charges,,,16.3,,,percent of total billed charges,,,16.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11,,,percent of total billed charges,,,13.19,,,percent of total billed charges,,,,,,,,,,,,,,,6.52,,,percent of total billed charges,,,,,,,,,6.03,,,percent of total billed charges,,,6.03,,,percent of total billed charges,,,,,,,,,16.3,,,percent of total billed charges,,,16.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.3,,,percent of total billed charges,,,16.3,,,percent of total billed charges,,,,,,,,,,,,,,,16.3,,,percent of total billed charges,,,16.3,,,percent of total billed charges,,,,,,,,,15.16,,,percent of total billed charges,,,,,,,,,,,,,,,15.16,,,percent of total billed charges,,,15.16,,,percent of total billed charges,,,15.16,,,percent of total billed charges,,,12.23,,,percent of total billed charges,,,16.3,,,percent of total billed charges,,,16.3,,,percent of total billed charges,,,16.3,,,percent of total billed charges,,,,,,,,,11.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.6,,,percent of total billed charges,,
CAPSAICIN HP 0.075  CR 30 GM,2500008106,CDM,637,RC,536111825,NDC,999,EAPG,,,,outpatient,facility,60,UN,16.3,16.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAPTOPRIL 12.5 MG TAB,2500008110,CDM,637,RC,2724116001,NDC,,,,,,inpatient,facility,12.5,UN,5.15,5.15,0.41,5.15,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,,,,,,,5.15,,,percent of total billed charges,,,2.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.09,,,percent of total billed charges,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,
CAPTOPRIL 12.5 MG TAB,2500008110,CDM,637,RC,2724116001,NDC,,,,,,outpatient,facility,12.5,UN,5.15,5.15,0.41,548.68,,3.65,,,percent of total billed charges,,,1.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.15,,,percent of total billed charges,,,3.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.88,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.15,,,fee schedule,,,5.15,,,percent of total billed charges,,,,,,,,,5.15,,,percent of total billed charges,,,3.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.67,,,percent of total billed charges,,,,,,,,,,,,,,,2.78,,,percent of total billed charges,,,2.68,,,percent of total billed charges,,,2.83,,,percent of total billed charges,,,,,,,,,3.04,,,percent of total billed charges,,,548.68,,,per diem,,,5.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.15,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,4.17,,,percent of total billed charges,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,,,,,,,,1.91,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,,,,,,,5.15,,,percent of total billed charges,,,5.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.41,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,,,,,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,4.79,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,3.86,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,,,,,,,3.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.03,,,percent of total billed charges,,
CAPTOPRIL 12.5 MG TAB,2500008110,CDM,637,RC,2724116001,NDC,999,EAPG,,,,outpatient,facility,12.5,UN,5.15,5.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CAPTOPRIL 25 MG TAB,2500008113,CDM,637,RC,2724116101,NDC,,,,,,inpatient,facility,25,UN,4.19,4.19,0.34,4.19,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,4.19,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,
CAPTOPRIL 25 MG TAB,2500008113,CDM,637,RC,2724116101,NDC,,,,,,outpatient,facility,25,UN,4.19,4.19,0.34,548.68,,2.97,,,percent of total billed charges,,,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.19,,,percent of total billed charges,,,2.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.53,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.19,,,fee schedule,,,4.19,,,percent of total billed charges,,,,,,,,,4.19,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,,,,,,,2.47,,,percent of total billed charges,,,548.68,,,per diem,,,4.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.19,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.83,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,4.19,,,percent of total billed charges,,,4.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.34,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,3.9,,,percent of total billed charges,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,3.9,,,percent of total billed charges,,,3.9,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.47,,,percent of total billed charges,,
CAPTOPRIL 25 MG TAB,2500008113,CDM,637,RC,2724116101,NDC,999,EAPG,,,,outpatient,facility,25,UN,4.19,4.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBACHOL 0.01  OP SOLN 1.5 ML,2500008120,CDM,637,RC,65002315,NDC,,,,,,inpatient,facility,1.5,UN,147.44,147.44,11.8,147.44,,,,,,,,,,,,,,147.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.44,,,percent of total billed charges,,,,,,,,,147.44,,,percent of total billed charges,,,75.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.46,,,percent of total billed charges,,,,,,,,,,,,,,,147.44,,,percent of total billed charges,,,125.32,,,percent of total billed charges,,,,,,,,,,,,,,,147.44,,,percent of total billed charges,,,78.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,147.44,,,percent of total billed charges,,,,,,,,,,,,,,,11.8,,,percent of total billed charges,,,147.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,147.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.87,,,percent of total billed charges,,
CARBACHOL 0.01  OP SOLN 1.5 ML,2500008120,CDM,637,RC,65002315,NDC,,,,,,outpatient,facility,1.5,UN,147.44,147.44,11.8,548.68,,104.55,,,percent of total billed charges,,,35.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,147.44,,,percent of total billed charges,,,92.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,103.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,103.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,147.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,53.96,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,147.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,147.44,,,fee schedule,,,147.44,,,percent of total billed charges,,,,,,,,,147.44,,,percent of total billed charges,,,90.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.05,,,percent of total billed charges,,,,,,,,,,,,,,,79.62,,,percent of total billed charges,,,76.67,,,percent of total billed charges,,,81.09,,,percent of total billed charges,,,,,,,,,86.99,,,percent of total billed charges,,,548.68,,,per diem,,,147.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,147.44,,,percent of total billed charges,,,125.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,78.31,,,percent of total billed charges,,,147.44,,,percent of total billed charges,,,147.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.46,,,percent of total billed charges,,,119.31,,,percent of total billed charges,,,,,,,,,,,,,,,58.98,,,percent of total billed charges,,,,,,,,,54.55,,,percent of total billed charges,,,54.55,,,percent of total billed charges,,,,,,,,,147.44,,,percent of total billed charges,,,147.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,147.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.8,,,percent of total billed charges,,,147.44,,,percent of total billed charges,,,,,,,,,,,,,,,147.44,,,percent of total billed charges,,,147.44,,,percent of total billed charges,,,,,,,,,137.15,,,percent of total billed charges,,,,,,,,,,,,,,,137.15,,,percent of total billed charges,,,137.15,,,percent of total billed charges,,,137.15,,,percent of total billed charges,,,110.58,,,percent of total billed charges,,,147.44,,,percent of total billed charges,,,147.44,,,percent of total billed charges,,,147.44,,,percent of total billed charges,,,,,,,,,103.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,86.87,,,percent of total billed charges,,
CARBACHOL 0.01  OP SOLN 1.5 ML,2500008120,CDM,637,RC,65002315,NDC,999,EAPG,,,,outpatient,facility,1.5,UN,147.44,147.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBAMAZEPINE 100 MG CHEW TAB,2500008130,CDM,637,RC,904385461,NDC,,,,,,inpatient,facility,100,UN,1.68,1.68,0.13,1.68,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,
CARBAMAZEPINE 100 MG CHEW TAB,2500008130,CDM,637,RC,904385461,NDC,,,,,,outpatient,facility,100,UN,1.68,1.68,0.13,548.68,,1.19,,,percent of total billed charges,,,0.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.68,,,percent of total billed charges,,,1.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.68,,,fee schedule,,,1.68,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,548.68,,,per diem,,,1.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.68,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.99,,,percent of total billed charges,,
CARBAMAZEPINE 100 MG CHEW TAB,2500008130,CDM,637,RC,904385461,NDC,999,EAPG,,,,outpatient,facility,100,UN,1.68,1.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBAMAZEPINE 100 MG XR TAB,2500008131,CDM,637,RC,5167241231,NDC,,,,,,inpatient,facility,100,UN,3.76,3.76,0.3,3.76,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,
CARBAMAZEPINE 100 MG XR TAB,2500008131,CDM,637,RC,5167241231,NDC,,,,,,outpatient,facility,100,UN,3.76,3.76,0.3,548.68,,2.67,,,percent of total billed charges,,,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.76,,,percent of total billed charges,,,2.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.38,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.76,,,fee schedule,,,3.76,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,,,,,,,2.22,,,percent of total billed charges,,,548.68,,,per diem,,,3.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.76,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,1.39,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,2.82,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.22,,,percent of total billed charges,,
CARBAMAZEPINE 100 MG XR TAB,2500008131,CDM,637,RC,5167241231,NDC,999,EAPG,,,,outpatient,facility,100,UN,3.76,3.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBAMAZEPINE 200 MG/10 ML UDC,2500008136,CDM,637,RC,121172430,NDC,,,,,,inpatient,facility,10,UN,14.98,14.98,1.2,14.98,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,14.98,,,percent of total billed charges,,,7.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.99,,,percent of total billed charges,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,12.73,,,percent of total billed charges,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,7.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.83,,,percent of total billed charges,,
CARBAMAZEPINE 200 MG/10 ML UDC,2500008136,CDM,637,RC,121172430,NDC,,,,,,outpatient,facility,10,UN,14.98,14.98,1.2,548.68,,10.62,,,percent of total billed charges,,,3.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.98,,,percent of total billed charges,,,9.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.48,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.98,,,fee schedule,,,14.98,,,percent of total billed charges,,,,,,,,,14.98,,,percent of total billed charges,,,9.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.67,,,percent of total billed charges,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,8.24,,,percent of total billed charges,,,,,,,,,8.84,,,percent of total billed charges,,,548.68,,,per diem,,,14.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.98,,,percent of total billed charges,,,12.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.96,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.11,,,percent of total billed charges,,,12.12,,,percent of total billed charges,,,,,,,,,,,,,,,5.99,,,percent of total billed charges,,,,,,,,,5.54,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,,,,,,,14.98,,,percent of total billed charges,,,14.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.2,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,11.23,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,10.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.83,,,percent of total billed charges,,
CARBAMAZEPINE 200 MG/10 ML UDC,2500008136,CDM,637,RC,121172430,NDC,999,EAPG,,,,outpatient,facility,10,UN,14.98,14.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBAMAZEPINE 200 MG TAB,2500008140,CDM,637,RC,904617261,NDC,,,,,,inpatient,facility,200,UN,2.97,2.97,0.24,2.97,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,
CARBAMAZEPINE 200 MG TAB,2500008140,CDM,637,RC,904617261,NDC,,,,,,outpatient,facility,200,UN,2.97,2.97,0.24,548.68,,2.11,,,percent of total billed charges,,,0.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.97,,,percent of total billed charges,,,1.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.09,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.97,,,fee schedule,,,2.97,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,548.68,,,per diem,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.97,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,2.76,,,percent of total billed charges,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.75,,,percent of total billed charges,,
CARBAMAZEPINE 200 MG TAB,2500008140,CDM,637,RC,904617261,NDC,999,EAPG,,,,outpatient,facility,200,UN,2.97,2.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBAMIDE PEROX 6.5  OTIC 15ML,2500008154,CDM,637,RC,904662735,NDC,,,,,,inpatient,facility,15,UN,2.84,2.84,0.23,2.84,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,2.84,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,
CARBAMIDE PEROX 6.5  OTIC 15ML,2500008154,CDM,637,RC,904662735,NDC,,,,,,outpatient,facility,15,UN,2.84,2.84,0.23,548.68,,2.01,,,percent of total billed charges,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.84,,,percent of total billed charges,,,1.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.04,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.84,,,fee schedule,,,2.84,,,percent of total billed charges,,,,,,,,,2.84,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,548.68,,,per diem,,,2.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.84,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,,,,,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,2.84,,,percent of total billed charges,,,2.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.67,,,percent of total billed charges,,
CARBAMIDE PEROX 6.5  OTIC 15ML,2500008154,CDM,637,RC,904662735,NDC,999,EAPG,,,,outpatient,facility,15,UN,2.84,2.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBIDOPA/LEVODOP 10/100 TAB,2500008170,CDM,637,RC,6275651788,NDC,,,,,,inpatient,facility,1,UN,0.86,0.86,0.07,0.86,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,0.86,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 10/100 TAB,2500008170,CDM,637,RC,6275651788,NDC,,,,,,outpatient,facility,1,UN,0.86,0.86,0.07,548.68,,0.61,,,percent of total billed charges,,,0.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.86,,,percent of total billed charges,,,0.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.31,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.86,,,fee schedule,,,0.86,,,percent of total billed charges,,,,,,,,,0.86,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,,,,,,,0.51,,,percent of total billed charges,,,548.68,,,per diem,,,0.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.86,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,0.32,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,0.86,,,percent of total billed charges,,,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.51,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 10/100 TAB,2500008170,CDM,637,RC,6275651788,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.86,0.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBIDOPA/LEVODOP 25/100 TAB,2500008172,CDM,637,RC,904623761,NDC,,,,,,inpatient,facility,1,UN,0.62,0.62,0.05,0.62,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 25/100 TAB,2500008172,CDM,637,RC,904623761,NDC,,,,,,outpatient,facility,1,UN,0.62,0.62,0.05,548.68,,0.44,,,percent of total billed charges,,,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.62,,,percent of total billed charges,,,0.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.62,,,fee schedule,,,0.62,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,0.37,,,percent of total billed charges,,,548.68,,,per diem,,,0.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.62,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.37,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 25/100 TAB,2500008172,CDM,637,RC,904623761,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.62,0.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBIDOPA/LEVODOP 25/100 TABCR,2500008173,CDM,637,RC,5107997801,NDC,,,,,,inpatient,facility,1,UN,5.74,5.74,0.46,5.74,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,5.74,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,4.88,,,percent of total billed charges,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 25/100 TABCR,2500008173,CDM,637,RC,5107997801,NDC,,,,,,outpatient,facility,1,UN,5.74,5.74,0.46,548.68,,4.07,,,percent of total billed charges,,,1.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.74,,,percent of total billed charges,,,3.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.74,,,fee schedule,,,5.74,,,percent of total billed charges,,,,,,,,,5.74,,,percent of total billed charges,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,3.16,,,percent of total billed charges,,,,,,,,,3.39,,,percent of total billed charges,,,548.68,,,per diem,,,5.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.74,,,percent of total billed charges,,,4.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.05,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,4.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,,,,,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,5.74,,,percent of total billed charges,,,5.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,5.34,,,percent of total billed charges,,,,,,,,,,,,,,,5.34,,,percent of total billed charges,,,5.34,,,percent of total billed charges,,,5.34,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.38,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 25/100 TABCR,2500008173,CDM,637,RC,5107997801,NDC,999,EAPG,,,,outpatient,facility,1,UN,5.74,5.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBIDOPA/LEVODOP 25/250 TAB,2500008174,CDM,637,RC,904623861,NDC,,,,,,inpatient,facility,1,UN,0.82,0.82,0.07,0.82,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 25/250 TAB,2500008174,CDM,637,RC,904623861,NDC,,,,,,outpatient,facility,1,UN,0.82,0.82,0.07,548.68,,0.58,,,percent of total billed charges,,,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.82,,,percent of total billed charges,,,0.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.82,,,fee schedule,,,0.82,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,0.48,,,percent of total billed charges,,,548.68,,,per diem,,,0.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.82,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.48,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 25/250 TAB,2500008174,CDM,637,RC,904623861,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.82,0.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARBIDOPA/LEVODOP 50/200 TABCR,2500008177,CDM,637,RC,5107992320,NDC,,,,,,inpatient,facility,1,UN,5.74,5.74,0.46,5.74,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,5.74,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,4.88,,,percent of total billed charges,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 50/200 TABCR,2500008177,CDM,637,RC,5107992320,NDC,,,,,,outpatient,facility,1,UN,5.74,5.74,0.46,548.68,,4.07,,,percent of total billed charges,,,1.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.74,,,percent of total billed charges,,,3.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.74,,,fee schedule,,,5.74,,,percent of total billed charges,,,,,,,,,5.74,,,percent of total billed charges,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,3.16,,,percent of total billed charges,,,,,,,,,3.39,,,percent of total billed charges,,,548.68,,,per diem,,,5.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.74,,,percent of total billed charges,,,4.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.05,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,4.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,,,,,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,5.74,,,percent of total billed charges,,,5.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,5.34,,,percent of total billed charges,,,,,,,,,,,,,,,5.34,,,percent of total billed charges,,,5.34,,,percent of total billed charges,,,5.34,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,5.74,,,percent of total billed charges,,,,,,,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.38,,,percent of total billed charges,,
CARBIDOPA/LEVODOP 50/200 TABCR,2500008177,CDM,637,RC,5107992320,NDC,999,EAPG,,,,outpatient,facility,1,UN,5.74,5.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARVEDILOL 6.25 MG TAB,2500008254,CDM,637,RC,904630161,NDC,,,,,,inpatient,facility,6.25,UN,0.29,0.29,0.02,0.29,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,
CARVEDILOL 6.25 MG TAB,2500008254,CDM,637,RC,904630161,NDC,,,,,,outpatient,facility,6.25,UN,0.29,0.29,0.02,548.68,,0.21,,,percent of total billed charges,,,0.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.29,,,percent of total billed charges,,,0.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.29,,,fee schedule,,,0.29,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,0.17,,,percent of total billed charges,,,548.68,,,per diem,,,0.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.29,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,0.11,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.17,,,percent of total billed charges,,
CARVEDILOL 6.25 MG TAB,2500008254,CDM,637,RC,904630161,NDC,999,EAPG,,,,outpatient,facility,6.25,UN,0.29,0.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFEPIME HCL 1 GM INJ,2500008322,CDM,636,RC,J0692,HCPCS,4456724010,NDC,,,,inpatient,facility,1,UN,22.57,22.57,1.81,22.57,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,,,,,,,22.57,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.54,,,percent of total billed charges,,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,19.18,,,percent of total billed charges,,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,11.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.3,,,percent of total billed charges,,
CEFEPIME HCL 1 GM INJ,2500008322,CDM,636,RC,J0692,HCPCS,4456724010,NDC,,,,outpatient,facility,1,UN,22.57,22.57,1.32,548.68,,16,,,percent of total billed charges,,,5.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,22.57,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.26,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,22.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,22.57,,,fee schedule,,,22.57,,,percent of total billed charges,,,,,,,,,22.57,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,13.32,,,percent of total billed charges,,,548.68,,,per diem,,,22.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,22.57,,,percent of total billed charges,,,19.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.99,,,percent of total billed charges,,,22.57,,,percent of total billed charges,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.23,,,percent of total billed charges,,,18.26,,,percent of total billed charges,,,,,,,,,,,,,,,9.03,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22.57,,,percent of total billed charges,,,22.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.81,,,percent of total billed charges,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.32,,,fee schedule,,,22.57,,,percent of total billed charges,,,22.57,,,percent of total billed charges,,,22.57,,,percent of total billed charges,,,,,,,,,15.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.3,,,percent of total billed charges,,
CEFEPIME HCL 1 GM INJ,2500008322,CDM,636,RC,J0692,HCPCS,4456724010,NDC,496,EAPG,,outpatient,facility,1,UN,22.57,22.57,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFEPIME HCL 2 GM INJ,2500008326,CDM,636,RC,J0692,HCPCS,4456724110,NDC,,,,inpatient,facility,2,UN,38.81,38.81,3.1,38.81,,,,,,,,,,,,,,38.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.81,,,percent of total billed charges,,,,,,,,,38.81,,,percent of total billed charges,,,19.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.29,,,percent of total billed charges,,,,,,,,,,,,,,,38.81,,,percent of total billed charges,,,32.99,,,percent of total billed charges,,,,,,,,,,,,,,,38.81,,,percent of total billed charges,,,20.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,38.81,,,percent of total billed charges,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,38.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.87,,,percent of total billed charges,,
CEFEPIME HCL 2 GM INJ,2500008326,CDM,636,RC,J0692,HCPCS,4456724110,NDC,,,,outpatient,facility,2,UN,38.81,38.81,1.32,548.68,,27.52,,,percent of total billed charges,,,9.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,38.81,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,38.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,14.2,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,38.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,38.81,,,fee schedule,,,38.81,,,percent of total billed charges,,,,,,,,,38.81,,,percent of total billed charges,,,23.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,22.9,,,percent of total billed charges,,,548.68,,,per diem,,,38.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,38.81,,,percent of total billed charges,,,32.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.61,,,percent of total billed charges,,,38.81,,,percent of total billed charges,,,38.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.18,,,percent of total billed charges,,,31.41,,,percent of total billed charges,,,,,,,,,,,,,,,15.52,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,38.81,,,percent of total billed charges,,,38.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,38.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.1,,,percent of total billed charges,,,38.81,,,percent of total billed charges,,,,,,,,,,,,,,,38.81,,,percent of total billed charges,,,38.81,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.32,,,fee schedule,,,38.81,,,percent of total billed charges,,,38.81,,,percent of total billed charges,,,38.81,,,percent of total billed charges,,,,,,,,,27.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,22.87,,,percent of total billed charges,,
CEFEPIME HCL 2 GM INJ,2500008326,CDM,636,RC,J0692,HCPCS,4456724110,NDC,496,EAPG,,outpatient,facility,2,UN,38.81,38.81,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFPODOXIME 200 MG TAB,2500008342,CDM,637,RC,6586209620,NDC,,,,,,inpatient,facility,200,UN,27.92,27.92,2.23,27.92,,,,,,,,,,,,,,27.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.92,,,percent of total billed charges,,,,,,,,,27.92,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.75,,,percent of total billed charges,,,,,,,,,,,,,,,27.92,,,percent of total billed charges,,,23.73,,,percent of total billed charges,,,,,,,,,,,,,,,27.92,,,percent of total billed charges,,,14.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,27.92,,,percent of total billed charges,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,27.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.45,,,percent of total billed charges,,
CEFPODOXIME 200 MG TAB,2500008342,CDM,637,RC,6586209620,NDC,,,,,,outpatient,facility,200,UN,27.92,27.92,2.23,548.68,,19.8,,,percent of total billed charges,,,6.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,27.92,,,percent of total billed charges,,,17.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,19.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,19.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,27.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,27.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,27.92,,,fee schedule,,,27.92,,,percent of total billed charges,,,,,,,,,27.92,,,percent of total billed charges,,,17.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.89,,,percent of total billed charges,,,,,,,,,,,,,,,15.08,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,,,,,,,16.47,,,percent of total billed charges,,,548.68,,,per diem,,,27.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,27.92,,,percent of total billed charges,,,23.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.83,,,percent of total billed charges,,,27.92,,,percent of total billed charges,,,27.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.83,,,percent of total billed charges,,,22.59,,,percent of total billed charges,,,,,,,,,,,,,,,11.17,,,percent of total billed charges,,,,,,,,,10.33,,,percent of total billed charges,,,10.33,,,percent of total billed charges,,,,,,,,,27.92,,,percent of total billed charges,,,27.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.23,,,percent of total billed charges,,,27.92,,,percent of total billed charges,,,,,,,,,,,,,,,27.92,,,percent of total billed charges,,,27.92,,,percent of total billed charges,,,,,,,,,25.97,,,percent of total billed charges,,,,,,,,,,,,,,,25.97,,,percent of total billed charges,,,25.97,,,percent of total billed charges,,,25.97,,,percent of total billed charges,,,20.94,,,percent of total billed charges,,,27.92,,,percent of total billed charges,,,27.92,,,percent of total billed charges,,,27.92,,,percent of total billed charges,,,,,,,,,19.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,16.45,,,percent of total billed charges,,
CEFPODOXIME 200 MG TAB,2500008342,CDM,637,RC,6586209620,NDC,999,EAPG,,,,outpatient,facility,200,UN,27.92,27.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFUROXIME AXETIL 250 MG TAB,2500008370,CDM,637,RC,6818030260,NDC,,,,,,inpatient,facility,250,UN,14.52,14.52,1.16,14.52,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,,,,,,,14.52,,,percent of total billed charges,,,7.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,12.34,,,percent of total billed charges,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,7.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.56,,,percent of total billed charges,,
CEFUROXIME AXETIL 250 MG TAB,2500008370,CDM,637,RC,6818030260,NDC,,,,,,outpatient,facility,250,UN,14.52,14.52,1.16,548.68,,10.3,,,percent of total billed charges,,,3.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.52,,,percent of total billed charges,,,9.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.31,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.52,,,fee schedule,,,14.52,,,percent of total billed charges,,,,,,,,,14.52,,,percent of total billed charges,,,8.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.35,,,percent of total billed charges,,,,,,,,,,,,,,,7.84,,,percent of total billed charges,,,7.55,,,percent of total billed charges,,,7.99,,,percent of total billed charges,,,,,,,,,8.57,,,percent of total billed charges,,,548.68,,,per diem,,,14.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.52,,,percent of total billed charges,,,12.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.71,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.8,,,percent of total billed charges,,,11.75,,,percent of total billed charges,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,,,,,,,5.37,,,percent of total billed charges,,,5.37,,,percent of total billed charges,,,,,,,,,14.52,,,percent of total billed charges,,,14.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.16,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,,,,,,,13.51,,,percent of total billed charges,,,,,,,,,,,,,,,13.51,,,percent of total billed charges,,,13.51,,,percent of total billed charges,,,13.51,,,percent of total billed charges,,,10.89,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,,,,,,,10.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.26,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.56,,,percent of total billed charges,,
CEFUROXIME AXETIL 250 MG TAB,2500008370,CDM,637,RC,6818030260,NDC,999,EAPG,,,,outpatient,facility,250,UN,14.52,14.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CELECOXIB 100 MG CAP,2500008380,CDM,637,RC,904650261,NDC,,,,,,inpatient,facility,100,UN,3.99,3.99,0.32,3.99,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,
CELECOXIB 100 MG CAP,2500008380,CDM,637,RC,904650261,NDC,,,,,,outpatient,facility,100,UN,3.99,3.99,0.32,548.68,,2.83,,,percent of total billed charges,,,0.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.99,,,percent of total billed charges,,,2.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.99,,,fee schedule,,,3.99,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,2.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,2.35,,,percent of total billed charges,,,548.68,,,per diem,,,3.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.99,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.69,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,1.48,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,3.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.32,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,3.71,,,percent of total billed charges,,,,,,,,,,,,,,,3.71,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.35,,,percent of total billed charges,,
CELECOXIB 100 MG CAP,2500008380,CDM,637,RC,904650261,NDC,999,EAPG,,,,outpatient,facility,100,UN,3.99,3.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEPACOL LOZENGE,2500008390,CDM,637,RC,904625549,NDC,,,,,,inpatient,facility,1,UN,0.53,0.53,0.04,0.53,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,0.53,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,
CEPACOL LOZENGE,2500008390,CDM,637,RC,904625549,NDC,,,,,,outpatient,facility,1,UN,0.53,0.53,0.04,548.68,,0.38,,,percent of total billed charges,,,0.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.53,,,percent of total billed charges,,,0.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.19,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.53,,,fee schedule,,,0.53,,,percent of total billed charges,,,,,,,,,0.53,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.31,,,percent of total billed charges,,,548.68,,,per diem,,,0.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.53,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,0.2,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,0.53,,,percent of total billed charges,,,0.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.31,,,percent of total billed charges,,
CEPACOL LOZENGE,2500008390,CDM,637,RC,904625549,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.53,0.53,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEPHALEXIN HCL 250 MG CAP,2500008400,CDM,637,RC,6068715201,NDC,,,,,,inpatient,facility,250,UN,2.34,2.34,0.19,2.34,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,2.34,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,
CEPHALEXIN HCL 250 MG CAP,2500008400,CDM,637,RC,6068715201,NDC,,,,,,outpatient,facility,250,UN,2.34,2.34,0.19,548.68,,1.66,,,percent of total billed charges,,,0.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.34,,,percent of total billed charges,,,1.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.86,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.34,,,fee schedule,,,2.34,,,percent of total billed charges,,,,,,,,,2.34,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,1.38,,,percent of total billed charges,,,548.68,,,per diem,,,2.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.34,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,,,,,,,0.87,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,2.34,,,percent of total billed charges,,,2.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.19,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.38,,,percent of total billed charges,,
CEPHALEXIN HCL 250 MG CAP,2500008400,CDM,637,RC,6068715201,NDC,999,EAPG,,,,outpatient,facility,250,UN,2.34,2.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEPHALEXIN HCL 500 MG CAP,2500008402,CDM,637,RC,5026815215,NDC,,,,,,inpatient,facility,500,UN,4.03,4.03,0.32,4.03,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,4.03,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.42,,,percent of total billed charges,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,
CEPHALEXIN HCL 500 MG CAP,2500008402,CDM,637,RC,5026815215,NDC,,,,,,outpatient,facility,500,UN,4.03,4.03,0.32,548.68,,2.86,,,percent of total billed charges,,,0.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.03,,,percent of total billed charges,,,2.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.47,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.03,,,fee schedule,,,4.03,,,percent of total billed charges,,,,,,,,,4.03,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.1,,,percent of total billed charges,,,2.22,,,percent of total billed charges,,,,,,,,,2.38,,,percent of total billed charges,,,548.68,,,per diem,,,4.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.03,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,1.49,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,4.03,,,percent of total billed charges,,,4.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.32,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,3.75,,,percent of total billed charges,,,,,,,,,,,,,,,3.75,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,3.02,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,2.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.37,,,percent of total billed charges,,
CEPHALEXIN HCL 500 MG CAP,2500008402,CDM,637,RC,5026815215,NDC,999,EAPG,,,,outpatient,facility,500,UN,4.03,4.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CETIRIZINE HCL 10 MG TAB,2500008470,CDM,637,RC,904671761,NDC,,,,,,inpatient,facility,10,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
CETIRIZINE HCL 10 MG TAB,2500008470,CDM,637,RC,904671761,NDC,,,,,,outpatient,facility,10,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
CETIRIZINE HCL 10 MG TAB,2500008470,CDM,637,RC,904671761,NDC,999,EAPG,,,,outpatient,facility,10,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHARCOAL/SORBITOL 25 GM/120ML,2500008500,CDM,637,RC,574012074,NDC,,,,,,inpatient,facility,120,UN,25.05,25.05,2,25.05,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,25.05,,,percent of total billed charges,,,12.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.03,,,percent of total billed charges,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,21.29,,,percent of total billed charges,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.76,,,percent of total billed charges,,
CHARCOAL/SORBITOL 25 GM/120ML,2500008500,CDM,637,RC,574012074,NDC,,,,,,outpatient,facility,120,UN,25.05,25.05,2,548.68,,17.76,,,percent of total billed charges,,,6.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,25.05,,,percent of total billed charges,,,15.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,17.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,17.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.17,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,25.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,25.05,,,fee schedule,,,25.05,,,percent of total billed charges,,,,,,,,,25.05,,,percent of total billed charges,,,15.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.85,,,percent of total billed charges,,,,,,,,,,,,,,,13.53,,,percent of total billed charges,,,13.03,,,percent of total billed charges,,,13.78,,,percent of total billed charges,,,,,,,,,14.78,,,percent of total billed charges,,,548.68,,,per diem,,,25.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,25.05,,,percent of total billed charges,,,21.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.3,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,20.27,,,percent of total billed charges,,,,,,,,,,,,,,,10.02,,,percent of total billed charges,,,,,,,,,9.27,,,percent of total billed charges,,,9.27,,,percent of total billed charges,,,,,,,,,25.05,,,percent of total billed charges,,,25.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,23.3,,,percent of total billed charges,,,,,,,,,,,,,,,23.3,,,percent of total billed charges,,,23.3,,,percent of total billed charges,,,23.3,,,percent of total billed charges,,,18.79,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.76,,,percent of total billed charges,,
CHARCOAL/SORBITOL 25 GM/120ML,2500008500,CDM,637,RC,574012074,NDC,999,EAPG,,,,outpatient,facility,120,UN,25.05,25.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHARCOAL/WATER 25 GM/120 ML,2500008510,CDM,637,RC,574052174,NDC,,,,,,inpatient,facility,120,UN,25.05,25.05,2,25.05,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,25.05,,,percent of total billed charges,,,12.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.03,,,percent of total billed charges,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,21.29,,,percent of total billed charges,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.76,,,percent of total billed charges,,
CHARCOAL/WATER 25 GM/120 ML,2500008510,CDM,637,RC,574052174,NDC,,,,,,outpatient,facility,120,UN,25.05,25.05,2,548.68,,17.76,,,percent of total billed charges,,,6.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,25.05,,,percent of total billed charges,,,15.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,17.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,17.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.17,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,25.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,25.05,,,fee schedule,,,25.05,,,percent of total billed charges,,,,,,,,,25.05,,,percent of total billed charges,,,15.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.85,,,percent of total billed charges,,,,,,,,,,,,,,,13.53,,,percent of total billed charges,,,13.03,,,percent of total billed charges,,,13.78,,,percent of total billed charges,,,,,,,,,14.78,,,percent of total billed charges,,,548.68,,,per diem,,,25.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,25.05,,,percent of total billed charges,,,21.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.3,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,20.27,,,percent of total billed charges,,,,,,,,,,,,,,,10.02,,,percent of total billed charges,,,,,,,,,9.27,,,percent of total billed charges,,,9.27,,,percent of total billed charges,,,,,,,,,25.05,,,percent of total billed charges,,,25.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,,,,,,,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,23.3,,,percent of total billed charges,,,,,,,,,,,,,,,23.3,,,percent of total billed charges,,,23.3,,,percent of total billed charges,,,23.3,,,percent of total billed charges,,,18.79,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,25.05,,,percent of total billed charges,,,,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.76,,,percent of total billed charges,,
CHARCOAL/WATER 25 GM/120 ML,2500008510,CDM,637,RC,574052174,NDC,999,EAPG,,,,outpatient,facility,120,UN,25.05,25.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLORDIAZEPOXIDE 25 MG CAP,2500008573,CDM,637,RC,555015904,NDC,,,,,,inpatient,facility,25,UN,1.02,1.02,0.08,1.02,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,
CHLORDIAZEPOXIDE 25 MG CAP,2500008573,CDM,637,RC,555015904,NDC,,,,,,outpatient,facility,25,UN,1.02,1.02,0.08,548.68,,0.72,,,percent of total billed charges,,,0.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.02,,,percent of total billed charges,,,0.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.37,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.02,,,fee schedule,,,1.02,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.6,,,percent of total billed charges,,,548.68,,,per diem,,,1.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.02,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,0.38,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.6,,,percent of total billed charges,,
CHLORDIAZEPOXIDE 25 MG CAP,2500008573,CDM,637,RC,555015904,NDC,999,EAPG,,,,outpatient,facility,25,UN,1.02,1.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLORDIAZEPOXIDE 5 MG CAP,2500008575,CDM,637,RC,555015802,NDC,,,,,,inpatient,facility,5,UN,1.15,1.15,0.09,1.15,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,1.15,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,
CHLORDIAZEPOXIDE 5 MG CAP,2500008575,CDM,637,RC,555015802,NDC,,,,,,outpatient,facility,5,UN,1.15,1.15,0.09,548.68,,0.82,,,percent of total billed charges,,,0.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.15,,,percent of total billed charges,,,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.42,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.15,,,fee schedule,,,1.15,,,percent of total billed charges,,,,,,,,,1.15,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,0.68,,,percent of total billed charges,,,548.68,,,per diem,,,1.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.15,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,1.15,,,percent of total billed charges,,,1.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.68,,,percent of total billed charges,,
CHLORDIAZEPOXIDE 5 MG CAP,2500008575,CDM,637,RC,555015802,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.15,1.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLORHEXIDINE 0.12  15 ML UDC,2500008590,CDM,637,RC,6933913815,NDC,,,,,,inpatient,facility,15,UN,7.89,7.89,0.63,7.89,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,,,,,,,7.89,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.73,,,percent of total billed charges,,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,6.71,,,percent of total billed charges,,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,
CHLORHEXIDINE 0.12  15 ML UDC,2500008590,CDM,637,RC,6933913815,NDC,,,,,,outpatient,facility,15,UN,7.89,7.89,0.63,548.68,,5.59,,,percent of total billed charges,,,1.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.89,,,percent of total billed charges,,,4.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.89,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.89,,,fee schedule,,,7.89,,,percent of total billed charges,,,,,,,,,7.89,,,percent of total billed charges,,,4.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.62,,,percent of total billed charges,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,4.1,,,percent of total billed charges,,,4.34,,,percent of total billed charges,,,,,,,,,4.66,,,percent of total billed charges,,,548.68,,,per diem,,,7.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.89,,,percent of total billed charges,,,6.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.38,,,percent of total billed charges,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,,,,,,,2.92,,,percent of total billed charges,,,2.92,,,percent of total billed charges,,,,,,,,,7.89,,,percent of total billed charges,,,7.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.63,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,,,,,,,7.34,,,percent of total billed charges,,,,,,,,,,,,,,,7.34,,,percent of total billed charges,,,7.34,,,percent of total billed charges,,,7.34,,,percent of total billed charges,,,5.92,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,,,,,,,5.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.65,,,percent of total billed charges,,
CHLORHEXIDINE 0.12  15 ML UDC,2500008590,CDM,637,RC,6933913815,NDC,999,EAPG,,,,outpatient,facility,15,UN,7.89,7.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLORTHALIDONE 25 MG TAB,2500008702,CDM,637,RC,4359871901,NDC,,,,,,inpatient,facility,25,UN,3.99,3.99,0.32,3.99,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,
CHLORTHALIDONE 25 MG TAB,2500008702,CDM,637,RC,4359871901,NDC,,,,,,outpatient,facility,25,UN,3.99,3.99,0.32,548.68,,2.83,,,percent of total billed charges,,,0.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.99,,,percent of total billed charges,,,2.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.99,,,fee schedule,,,3.99,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,2.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,2.35,,,percent of total billed charges,,,548.68,,,per diem,,,3.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.99,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,1.48,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,3.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.32,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,3.71,,,percent of total billed charges,,,,,,,,,,,,,,,3.71,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.35,,,percent of total billed charges,,
CHLORTHALIDONE 25 MG TAB,2500008702,CDM,637,RC,4359871901,NDC,999,EAPG,,,,outpatient,facility,25,UN,3.99,3.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHOLECALCIFEROL 400 UNIT TAB,2500008730,CDM,637,RC,7733394810,NDC,,,,,,inpatient,facility,400,UN,1,1,0.08,1,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,1,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,
CHOLECALCIFEROL 400 UNIT TAB,2500008730,CDM,637,RC,7733394810,NDC,,,,,,outpatient,facility,400,UN,1,1,0.08,548.68,,0.71,,,percent of total billed charges,,,0.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1,,,percent of total billed charges,,,0.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.37,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1,,,fee schedule,,,1,,,percent of total billed charges,,,,,,,,,1,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,548.68,,,per diem,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,1,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,0.37,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,1,,,percent of total billed charges,,,1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,1,,,percent of total billed charges,,,1,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.59,,,percent of total billed charges,,
CHOLECALCIFEROL 400 UNIT TAB,2500008730,CDM,637,RC,7733394810,NDC,999,EAPG,,,,outpatient,facility,400,UN,1,1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CILOSTAZOL 100 MG TAB,2500008810,CDM,637,RC,5026817715,NDC,,,,,,inpatient,facility,100,UN,7.43,7.43,0.59,7.43,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,,,,,,,7.43,,,percent of total billed charges,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,6.32,,,percent of total billed charges,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,3.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.38,,,percent of total billed charges,,
CILOSTAZOL 100 MG TAB,2500008810,CDM,637,RC,5026817715,NDC,,,,,,outpatient,facility,100,UN,7.43,7.43,0.59,548.68,,5.27,,,percent of total billed charges,,,1.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.43,,,percent of total billed charges,,,4.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.72,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.43,,,fee schedule,,,7.43,,,percent of total billed charges,,,,,,,,,7.43,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.29,,,percent of total billed charges,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,,3.86,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,4.38,,,percent of total billed charges,,,548.68,,,per diem,,,7.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.43,,,percent of total billed charges,,,6.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.95,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,2.75,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,,,,,,,7.43,,,percent of total billed charges,,,7.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.59,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,6.91,,,percent of total billed charges,,,,,,,,,,,,,,,6.91,,,percent of total billed charges,,,6.91,,,percent of total billed charges,,,6.91,,,percent of total billed charges,,,5.57,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.38,,,percent of total billed charges,,
CILOSTAZOL 100 MG TAB,2500008810,CDM,637,RC,5026817715,NDC,999,EAPG,,,,outpatient,facility,100,UN,7.43,7.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CILOSTAZOL 50 MG TAB,2500008812,CDM,637,RC,5026817615,NDC,,,,,,inpatient,facility,50,UN,7.36,7.36,0.59,7.36,,,,,,,,,,,,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.36,,,percent of total billed charges,,,,,,,,,7.36,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,7.36,,,percent of total billed charges,,,6.26,,,percent of total billed charges,,,,,,,,,,,,,,,7.36,,,percent of total billed charges,,,3.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.34,,,percent of total billed charges,,
CILOSTAZOL 50 MG TAB,2500008812,CDM,637,RC,5026817615,NDC,,,,,,outpatient,facility,50,UN,7.36,7.36,0.59,548.68,,5.22,,,percent of total billed charges,,,1.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.36,,,percent of total billed charges,,,4.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.69,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.36,,,fee schedule,,,7.36,,,percent of total billed charges,,,,,,,,,7.36,,,percent of total billed charges,,,4.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.24,,,percent of total billed charges,,,,,,,,,,,,,,,3.97,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,,,,,,,4.34,,,percent of total billed charges,,,548.68,,,per diem,,,7.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.36,,,percent of total billed charges,,,6.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.91,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.97,,,percent of total billed charges,,,5.96,,,percent of total billed charges,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,2.72,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,,,,,,,7.36,,,percent of total billed charges,,,7.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.59,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,7.36,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,,,,,,,6.85,,,percent of total billed charges,,,,,,,,,,,,,,,6.85,,,percent of total billed charges,,,6.85,,,percent of total billed charges,,,6.85,,,percent of total billed charges,,,5.52,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,,,,,,,5.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.34,,,percent of total billed charges,,
CILOSTAZOL 50 MG TAB,2500008812,CDM,637,RC,5026817615,NDC,999,EAPG,,,,outpatient,facility,50,UN,7.36,7.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CIPROFLOXACN 0.3  OPH SOL 5 ML,2500008837,CDM,637,RC,6931530805,NDC,,,,,,inpatient,facility,5,UN,46.2,46.2,3.7,46.2,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,23.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.72,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,39.27,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,24.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.22,,,percent of total billed charges,,
CIPROFLOXACN 0.3  OPH SOL 5 ML,2500008837,CDM,637,RC,6931530805,NDC,,,,,,outpatient,facility,5,UN,46.2,46.2,3.7,548.68,,32.76,,,percent of total billed charges,,,11.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,46.2,,,percent of total billed charges,,,28.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,32.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,32.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,16.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,46.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,46.2,,,fee schedule,,,46.2,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,28.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.92,,,percent of total billed charges,,,,,,,,,,,,,,,24.95,,,percent of total billed charges,,,24.02,,,percent of total billed charges,,,25.41,,,percent of total billed charges,,,,,,,,,27.26,,,percent of total billed charges,,,548.68,,,per diem,,,46.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,46.2,,,percent of total billed charges,,,39.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.54,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.17,,,percent of total billed charges,,,37.39,,,percent of total billed charges,,,,,,,,,,,,,,,18.48,,,percent of total billed charges,,,,,,,,,17.09,,,percent of total billed charges,,,17.09,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,42.98,,,percent of total billed charges,,,,,,,,,,,,,,,42.98,,,percent of total billed charges,,,42.98,,,percent of total billed charges,,,42.98,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,32.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,27.22,,,percent of total billed charges,,
CIPROFLOXACN 0.3  OPH SOL 5 ML,2500008837,CDM,637,RC,6931530805,NDC,999,EAPG,,,,outpatient,facility,5,UN,46.2,46.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CIPROFLOXACIN/HC 0.2 OTIC 10ML,2500008840,CDM,637,RC,78085526,NDC,,,,,,inpatient,facility,10,UN,1202.82,1202.82,96.23,1202.82,,,,,,,,,,,,,,1202.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1202.82,,,percent of total billed charges,,,,,,,,,1202.82,,,percent of total billed charges,,,614.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1024.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.69,,,percent of total billed charges,,,,,,,,,,,,,,,1202.82,,,percent of total billed charges,,,1022.4,,,percent of total billed charges,,,,,,,,,,,,,,,1202.82,,,percent of total billed charges,,,638.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,481.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1202.82,,,percent of total billed charges,,,,,,,,,,,,,,,96.23,,,percent of total billed charges,,,1202.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1202.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.7,,,percent of total billed charges,,
CIPROFLOXACIN/HC 0.2 OTIC 10ML,2500008840,CDM,637,RC,78085526,NDC,,,,,,outpatient,facility,10,UN,1202.82,1202.82,96.23,1202.82,,852.92,,,percent of total billed charges,,,293.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1202.82,,,percent of total billed charges,,,753.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,845.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,845.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1202.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,440.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1202.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1202.82,,,fee schedule,,,1202.82,,,percent of total billed charges,,,,,,,,,1202.82,,,percent of total billed charges,,,737.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,857.01,,,percent of total billed charges,,,,,,,,,,,,,,,649.52,,,percent of total billed charges,,,625.47,,,percent of total billed charges,,,661.55,,,percent of total billed charges,,,,,,,,,709.66,,,percent of total billed charges,,,548.68,,,per diem,,,1202.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1202.82,,,percent of total billed charges,,,1022.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,638.82,,,percent of total billed charges,,,1202.82,,,percent of total billed charges,,,1202.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,811.42,,,percent of total billed charges,,,973.32,,,percent of total billed charges,,,,,,,,,,,,,,,481.13,,,percent of total billed charges,,,,,,,,,445.04,,,percent of total billed charges,,,445.04,,,percent of total billed charges,,,,,,,,,1202.82,,,percent of total billed charges,,,1202.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1202.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,96.23,,,percent of total billed charges,,,1202.82,,,percent of total billed charges,,,,,,,,,,,,,,,1202.82,,,percent of total billed charges,,,1202.82,,,percent of total billed charges,,,,,,,,,1118.86,,,percent of total billed charges,,,,,,,,,,,,,,,1118.86,,,percent of total billed charges,,,1118.86,,,percent of total billed charges,,,1118.86,,,percent of total billed charges,,,902.12,,,percent of total billed charges,,,1202.82,,,percent of total billed charges,,,1202.82,,,percent of total billed charges,,,1202.82,,,percent of total billed charges,,,,,,,,,843.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,601.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,708.7,,,percent of total billed charges,,
CIPROFLOXACIN/HC 0.2 OTIC 10ML,2500008840,CDM,637,RC,78085526,NDC,999,EAPG,,,,outpatient,facility,10,UN,1202.82,1202.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CIPROFLOX/DEXAMETH OTIC 7.5 ML,2500008844,CDM,637,RC,4359832675,NDC,,,,,,inpatient,facility,7.5,UN,887.77,887.77,71.02,887.77,,,,,,,,,,,,,,887.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,887.77,,,percent of total billed charges,,,,,,,,,887.77,,,percent of total billed charges,,,453.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,756.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,532.66,,,percent of total billed charges,,,,,,,,,,,,,,,887.77,,,percent of total billed charges,,,754.6,,,percent of total billed charges,,,,,,,,,,,,,,,887.77,,,percent of total billed charges,,,471.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,887.77,,,percent of total billed charges,,,,,,,,,,,,,,,71.02,,,percent of total billed charges,,,887.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,887.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.07,,,percent of total billed charges,,
CIPROFLOX/DEXAMETH OTIC 7.5 ML,2500008844,CDM,637,RC,4359832675,NDC,,,,,,outpatient,facility,7.5,UN,887.77,887.77,71.02,887.77,,629.52,,,percent of total billed charges,,,216.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,887.77,,,percent of total billed charges,,,556.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,624.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,624.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,887.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,324.92,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,887.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,887.77,,,fee schedule,,,887.77,,,percent of total billed charges,,,,,,,,,887.77,,,percent of total billed charges,,,544.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,632.54,,,percent of total billed charges,,,,,,,,,,,,,,,479.4,,,percent of total billed charges,,,461.64,,,percent of total billed charges,,,488.27,,,percent of total billed charges,,,,,,,,,523.78,,,percent of total billed charges,,,548.68,,,per diem,,,887.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,887.77,,,percent of total billed charges,,,754.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.49,,,percent of total billed charges,,,887.77,,,percent of total billed charges,,,887.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,598.89,,,percent of total billed charges,,,718.38,,,percent of total billed charges,,,,,,,,,,,,,,,355.11,,,percent of total billed charges,,,,,,,,,328.47,,,percent of total billed charges,,,328.47,,,percent of total billed charges,,,,,,,,,887.77,,,percent of total billed charges,,,887.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,887.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,71.02,,,percent of total billed charges,,,887.77,,,percent of total billed charges,,,,,,,,,,,,,,,887.77,,,percent of total billed charges,,,887.77,,,percent of total billed charges,,,,,,,,,825.8,,,percent of total billed charges,,,,,,,,,,,,,,,825.8,,,percent of total billed charges,,,825.8,,,percent of total billed charges,,,825.8,,,percent of total billed charges,,,665.83,,,percent of total billed charges,,,887.77,,,percent of total billed charges,,,887.77,,,percent of total billed charges,,,887.77,,,percent of total billed charges,,,,,,,,,622.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,443.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,523.07,,,percent of total billed charges,,
CIPROFLOX/DEXAMETH OTIC 7.5 ML,2500008844,CDM,637,RC,4359832675,NDC,999,EAPG,,,,outpatient,facility,7.5,UN,887.77,887.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CISATRACURIUM BESY 200 MG/20ML,2500008862,CDM,250,RC,J3490,HCPCS,7006915110,NDC,,,,inpatient,facility,20,UN,1071.18,1071.18,85.69,1071.18,,,,,,,,,,,,,,1071.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1071.18,,,percent of total billed charges,,,,,,,,,1071.18,,,percent of total billed charges,,,546.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,912.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,642.71,,,percent of total billed charges,,,,,,,,,,,,,,,1071.18,,,percent of total billed charges,,,910.5,,,percent of total billed charges,,,,,,,,,,,,,,,1071.18,,,percent of total billed charges,,,568.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,428.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1071.18,,,percent of total billed charges,,,,,,,,,,,,,,,85.69,,,percent of total billed charges,,,1071.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1071.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.14,,,percent of total billed charges,,
CISATRACURIUM BESY 200 MG/20ML,2500008862,CDM,250,RC,J3490,HCPCS,7006915110,NDC,,,,outpatient,facility,20,UN,1071.18,1071.18,1.2,1071.18,,759.57,,,percent of total billed charges,,,261.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1071.18,,,percent of total billed charges,,,671.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,753.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,753.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1071.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,392.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,1071.18,,,fee schedule,,,1071.18,,,percent of total billed charges,,,,,,,,,1071.18,,,percent of total billed charges,,,656.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,763.22,,,percent of total billed charges,,,,,,,,,,,,,,,1071.18,,,percent of total billed charges,,,1071.18,,,percent of total billed charges,,,1071.18,,,percent of total billed charges,,,,,,,,,632,,,percent of total billed charges,,,548.68,,,per diem,,,1071.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1071.18,,,percent of total billed charges,,,910.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,568.9,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,722.62,,,percent of total billed charges,,,866.8,,,percent of total billed charges,,,,,,,,,,,,,,,428.47,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1071.18,,,percent of total billed charges,,,1071.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1071.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,85.69,,,percent of total billed charges,,,1071.18,,,percent of total billed charges,,,,,,,,,,,,,,,1071.18,,,percent of total billed charges,,,1071.18,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,803.38,,,percent of total billed charges,,,1071.18,,,percent of total billed charges,,,1071.18,,,percent of total billed charges,,,1071.18,,,percent of total billed charges,,,,,,,,,751,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,535.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,631.14,,,percent of total billed charges,,
CISATRACURIUM BESY 200 MG/20ML,2500008862,CDM,250,RC,J3490,HCPCS,7006915110,NDC,435,EAPG,,outpatient,facility,20,UN,1071.18,1071.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CITRIC ACID/ SOD CIT 30 ML UDC,2500008902,CDM,637,RC,121119000,NDC,,,,,,inpatient,facility,30,UN,18.28,18.28,1.46,18.28,,,,,,,,,,,,,,18.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.28,,,percent of total billed charges,,,,,,,,,18.28,,,percent of total billed charges,,,9.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.97,,,percent of total billed charges,,,,,,,,,,,,,,,18.28,,,percent of total billed charges,,,15.54,,,percent of total billed charges,,,,,,,,,,,,,,,18.28,,,percent of total billed charges,,,9.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,18.28,,,percent of total billed charges,,,,,,,,,,,,,,,1.46,,,percent of total billed charges,,,18.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.77,,,percent of total billed charges,,
CITRIC ACID/ SOD CIT 30 ML UDC,2500008902,CDM,637,RC,121119000,NDC,,,,,,outpatient,facility,30,UN,18.28,18.28,1.46,548.68,,12.96,,,percent of total billed charges,,,4.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,18.28,,,percent of total billed charges,,,11.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,12.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,12.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,18.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.69,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,18.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,18.28,,,fee schedule,,,18.28,,,percent of total billed charges,,,,,,,,,18.28,,,percent of total billed charges,,,11.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.02,,,percent of total billed charges,,,,,,,,,,,,,,,9.87,,,percent of total billed charges,,,9.51,,,percent of total billed charges,,,10.05,,,percent of total billed charges,,,,,,,,,10.79,,,percent of total billed charges,,,548.68,,,per diem,,,18.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,18.28,,,percent of total billed charges,,,15.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.71,,,percent of total billed charges,,,18.28,,,percent of total billed charges,,,18.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.33,,,percent of total billed charges,,,14.79,,,percent of total billed charges,,,,,,,,,,,,,,,7.31,,,percent of total billed charges,,,,,,,,,6.76,,,percent of total billed charges,,,6.76,,,percent of total billed charges,,,,,,,,,18.28,,,percent of total billed charges,,,18.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.46,,,percent of total billed charges,,,18.28,,,percent of total billed charges,,,,,,,,,,,,,,,18.28,,,percent of total billed charges,,,18.28,,,percent of total billed charges,,,,,,,,,17,,,percent of total billed charges,,,,,,,,,,,,,,,17,,,percent of total billed charges,,,17,,,percent of total billed charges,,,17,,,percent of total billed charges,,,13.71,,,percent of total billed charges,,,18.28,,,percent of total billed charges,,,18.28,,,percent of total billed charges,,,18.28,,,percent of total billed charges,,,,,,,,,12.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.77,,,percent of total billed charges,,
CITRIC ACID/ SOD CIT 30 ML UDC,2500008902,CDM,637,RC,121119000,NDC,999,EAPG,,,,outpatient,facility,30,UN,18.28,18.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLARITHROMYCIN 250 MG TAB,2500008912,CDM,637,RC,781196160,NDC,,,,,,inpatient,facility,250,UN,19.86,19.86,1.59,19.86,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,,,,19.86,,,percent of total billed charges,,,10.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.92,,,percent of total billed charges,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,16.88,,,percent of total billed charges,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,10.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.7,,,percent of total billed charges,,
CLARITHROMYCIN 250 MG TAB,2500008912,CDM,637,RC,781196160,NDC,,,,,,outpatient,facility,250,UN,19.86,19.86,1.59,548.68,,14.08,,,percent of total billed charges,,,4.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,19.86,,,percent of total billed charges,,,12.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,13.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,13.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.27,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,19.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,19.86,,,fee schedule,,,19.86,,,percent of total billed charges,,,,,,,,,19.86,,,percent of total billed charges,,,12.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,,,,,,,,,,10.72,,,percent of total billed charges,,,10.33,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,11.72,,,percent of total billed charges,,,548.68,,,per diem,,,19.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,19.86,,,percent of total billed charges,,,16.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.55,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.4,,,percent of total billed charges,,,16.07,,,percent of total billed charges,,,,,,,,,,,,,,,7.94,,,percent of total billed charges,,,,,,,,,7.35,,,percent of total billed charges,,,7.35,,,percent of total billed charges,,,,,,,,,19.86,,,percent of total billed charges,,,19.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.59,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,,,,,,,18.47,,,percent of total billed charges,,,,,,,,,,,,,,,18.47,,,percent of total billed charges,,,18.47,,,percent of total billed charges,,,18.47,,,percent of total billed charges,,,14.89,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,19.86,,,percent of total billed charges,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.7,,,percent of total billed charges,,
CLARITHROMYCIN 250 MG TAB,2500008912,CDM,637,RC,781196160,NDC,999,EAPG,,,,outpatient,facility,250,UN,19.86,19.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLINDAMYCIN HCL 150 MG CAP,2500008930,CDM,637,RC,904595961,NDC,,,,,,inpatient,facility,150,UN,1.09,1.09,0.09,1.09,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,
CLINDAMYCIN HCL 150 MG CAP,2500008930,CDM,637,RC,904595961,NDC,,,,,,outpatient,facility,150,UN,1.09,1.09,0.09,548.68,,0.77,,,percent of total billed charges,,,0.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.09,,,percent of total billed charges,,,0.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.09,,,fee schedule,,,1.09,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,0.64,,,percent of total billed charges,,,548.68,,,per diem,,,1.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.09,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.64,,,percent of total billed charges,,
CLINDAMYCIN HCL 150 MG CAP,2500008930,CDM,637,RC,904595961,NDC,999,EAPG,,,,outpatient,facility,150,UN,1.09,1.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLINDAMYCIN 1  TOP SOLN 60ML,2500008944,CDM,637,RC,4580256202,NDC,,,,,,inpatient,facility,60,UN,191,191,15.28,191,,,,,,,,,,,,,,191,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191,,,percent of total billed charges,,,,,,,,,191,,,percent of total billed charges,,,97.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.6,,,percent of total billed charges,,,,,,,,,,,,,,,191,,,percent of total billed charges,,,162.35,,,percent of total billed charges,,,,,,,,,,,,,,,191,,,percent of total billed charges,,,101.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,191,,,percent of total billed charges,,,,,,,,,,,,,,,15.28,,,percent of total billed charges,,,191,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,191,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.54,,,percent of total billed charges,,
CLINDAMYCIN 1  TOP SOLN 60ML,2500008944,CDM,637,RC,4580256202,NDC,,,,,,outpatient,facility,60,UN,191,191,15.28,548.68,,135.44,,,percent of total billed charges,,,46.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,191,,,percent of total billed charges,,,119.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,134.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,134.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,191,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,69.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,191,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,191,,,fee schedule,,,191,,,percent of total billed charges,,,,,,,,,191,,,percent of total billed charges,,,117.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.09,,,percent of total billed charges,,,,,,,,,,,,,,,103.14,,,percent of total billed charges,,,99.32,,,percent of total billed charges,,,105.05,,,percent of total billed charges,,,,,,,,,112.69,,,percent of total billed charges,,,548.68,,,per diem,,,191,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,191,,,percent of total billed charges,,,162.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,101.44,,,percent of total billed charges,,,191,,,percent of total billed charges,,,191,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.85,,,percent of total billed charges,,,154.56,,,percent of total billed charges,,,,,,,,,,,,,,,76.4,,,percent of total billed charges,,,,,,,,,70.67,,,percent of total billed charges,,,70.67,,,percent of total billed charges,,,,,,,,,191,,,percent of total billed charges,,,191,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,191,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.28,,,percent of total billed charges,,,191,,,percent of total billed charges,,,,,,,,,,,,,,,191,,,percent of total billed charges,,,191,,,percent of total billed charges,,,,,,,,,177.67,,,percent of total billed charges,,,,,,,,,,,,,,,177.67,,,percent of total billed charges,,,177.67,,,percent of total billed charges,,,177.67,,,percent of total billed charges,,,143.25,,,percent of total billed charges,,,191,,,percent of total billed charges,,,191,,,percent of total billed charges,,,191,,,percent of total billed charges,,,,,,,,,133.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,112.54,,,percent of total billed charges,,
CLINDAMYCIN 1  TOP SOLN 60ML,2500008944,CDM,637,RC,4580256202,NDC,999,EAPG,,,,outpatient,facility,60,UN,191,191,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLOMIPRAMINE HCL 25 MG CAP,2500009000,CDM,637,RC,4257134230,NDC,,,,,,inpatient,facility,25,UN,37.09,37.09,2.97,37.09,,,,,,,,,,,,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.09,,,percent of total billed charges,,,,,,,,,37.09,,,percent of total billed charges,,,18.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.25,,,percent of total billed charges,,,,,,,,,,,,,,,37.09,,,percent of total billed charges,,,31.53,,,percent of total billed charges,,,,,,,,,,,,,,,37.09,,,percent of total billed charges,,,19.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.85,,,percent of total billed charges,,
CLOMIPRAMINE HCL 25 MG CAP,2500009000,CDM,637,RC,4257134230,NDC,,,,,,outpatient,facility,25,UN,37.09,37.09,2.97,548.68,,26.3,,,percent of total billed charges,,,9.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,37.09,,,percent of total billed charges,,,23.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,26.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,26.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,13.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,37.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,37.09,,,fee schedule,,,37.09,,,percent of total billed charges,,,,,,,,,37.09,,,percent of total billed charges,,,22.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.43,,,percent of total billed charges,,,,,,,,,,,,,,,20.03,,,percent of total billed charges,,,19.29,,,percent of total billed charges,,,20.4,,,percent of total billed charges,,,,,,,,,21.88,,,percent of total billed charges,,,548.68,,,per diem,,,37.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,37.09,,,percent of total billed charges,,,31.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.7,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.02,,,percent of total billed charges,,,30.01,,,percent of total billed charges,,,,,,,,,,,,,,,14.84,,,percent of total billed charges,,,,,,,,,13.72,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,37.09,,,percent of total billed charges,,,37.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,37.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.97,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,37.09,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,,,,,,,34.5,,,percent of total billed charges,,,,,,,,,,,,,,,34.5,,,percent of total billed charges,,,34.5,,,percent of total billed charges,,,34.5,,,percent of total billed charges,,,27.82,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,,,,,,,26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,21.85,,,percent of total billed charges,,
CLOMIPRAMINE HCL 25 MG CAP,2500009000,CDM,637,RC,4257134230,NDC,999,EAPG,,,,outpatient,facility,25,UN,37.09,37.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLONAZEPAM 0.5 MG TAB,2500009010,CDM,637,RC,4354740610,NDC,,,,,,inpatient,facility,0.5,UN,2.48,2.48,0.2,2.48,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,2.48,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.46,,,percent of total billed charges,,
CLONAZEPAM 0.5 MG TAB,2500009010,CDM,637,RC,4354740610,NDC,,,,,,outpatient,facility,0.5,UN,2.48,2.48,0.2,548.68,,1.76,,,percent of total billed charges,,,0.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.48,,,percent of total billed charges,,,1.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.48,,,fee schedule,,,2.48,,,percent of total billed charges,,,,,,,,,2.48,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,1.46,,,percent of total billed charges,,,548.68,,,per diem,,,2.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.48,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,2.48,,,percent of total billed charges,,,2.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.46,,,percent of total billed charges,,
CLONAZEPAM 0.5 MG TAB,2500009010,CDM,637,RC,4354740610,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,2.48,2.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLONAZEPAM 1 MG TAB,2500009012,CDM,637,RC,4354740710,NDC,,,,,,inpatient,facility,1,UN,2.84,2.84,0.23,2.84,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,2.84,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,
CLONAZEPAM 1 MG TAB,2500009012,CDM,637,RC,4354740710,NDC,,,,,,outpatient,facility,1,UN,2.84,2.84,0.23,548.68,,2.01,,,percent of total billed charges,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.84,,,percent of total billed charges,,,1.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.04,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.84,,,fee schedule,,,2.84,,,percent of total billed charges,,,,,,,,,2.84,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,548.68,,,per diem,,,2.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.84,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,,,,,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,2.84,,,percent of total billed charges,,,2.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.67,,,percent of total billed charges,,
CLONAZEPAM 1 MG TAB,2500009012,CDM,637,RC,4354740710,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.84,2.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLONIDINE HCL 0.1 MG TAB,2500009020,CDM,637,RC,228212710,NDC,,,,,,inpatient,facility,0.1,UN,0.85,0.85,0.07,0.85,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,0.85,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,
CLONIDINE HCL 0.1 MG TAB,2500009020,CDM,637,RC,228212710,NDC,,,,,,outpatient,facility,0.1,UN,0.85,0.85,0.07,548.68,,0.6,,,percent of total billed charges,,,0.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.85,,,percent of total billed charges,,,0.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.31,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.85,,,fee schedule,,,0.85,,,percent of total billed charges,,,,,,,,,0.85,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,,,,,,,0.5,,,percent of total billed charges,,,548.68,,,per diem,,,0.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.85,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,0.31,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,0.85,,,percent of total billed charges,,,0.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.5,,,percent of total billed charges,,
CLONIDINE HCL 0.1 MG TAB,2500009020,CDM,637,RC,228212710,NDC,999,EAPG,,,,outpatient,facility,0.1,UN,0.85,0.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLONIDINE HCL 0.2 MG TAB,2500009022,CDM,637,RC,6068712401,NDC,,,,,,inpatient,facility,0.2,UN,1.22,1.22,0.1,1.22,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,
CLONIDINE HCL 0.2 MG TAB,2500009022,CDM,637,RC,6068712401,NDC,,,,,,outpatient,facility,0.2,UN,1.22,1.22,0.1,548.68,,0.87,,,percent of total billed charges,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.22,,,percent of total billed charges,,,0.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.45,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.22,,,fee schedule,,,1.22,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,0.72,,,percent of total billed charges,,,548.68,,,per diem,,,1.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.22,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,0.45,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.72,,,percent of total billed charges,,
CLONIDINE HCL 0.2 MG TAB,2500009022,CDM,637,RC,6068712401,NDC,999,EAPG,,,,outpatient,facility,0.2,UN,1.22,1.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLONIDINE-TTS 0.1MG/24HR PATCH,2500009030,CDM,637,RC,378087199,NDC,,,,,,inpatient,facility,1,UN,109.3,109.3,8.74,109.3,,,,,,,,,,,,,,109.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.3,,,percent of total billed charges,,,,,,,,,109.3,,,percent of total billed charges,,,55.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.58,,,percent of total billed charges,,,,,,,,,,,,,,,109.3,,,percent of total billed charges,,,92.9,,,percent of total billed charges,,,,,,,,,,,,,,,109.3,,,percent of total billed charges,,,58.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,109.3,,,percent of total billed charges,,,,,,,,,,,,,,,8.74,,,percent of total billed charges,,,109.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.4,,,percent of total billed charges,,
CLONIDINE-TTS 0.1MG/24HR PATCH,2500009030,CDM,637,RC,378087199,NDC,,,,,,outpatient,facility,1,UN,109.3,109.3,8.74,548.68,,77.5,,,percent of total billed charges,,,26.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,109.3,,,percent of total billed charges,,,68.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,76.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,76.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,109.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,40,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,109.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,109.3,,,fee schedule,,,109.3,,,percent of total billed charges,,,,,,,,,109.3,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.88,,,percent of total billed charges,,,,,,,,,,,,,,,59.02,,,percent of total billed charges,,,56.84,,,percent of total billed charges,,,60.12,,,percent of total billed charges,,,,,,,,,64.49,,,percent of total billed charges,,,548.68,,,per diem,,,109.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,109.3,,,percent of total billed charges,,,92.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.05,,,percent of total billed charges,,,109.3,,,percent of total billed charges,,,109.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.73,,,percent of total billed charges,,,88.45,,,percent of total billed charges,,,,,,,,,,,,,,,43.72,,,percent of total billed charges,,,,,,,,,40.44,,,percent of total billed charges,,,40.44,,,percent of total billed charges,,,,,,,,,109.3,,,percent of total billed charges,,,109.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,109.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.74,,,percent of total billed charges,,,109.3,,,percent of total billed charges,,,,,,,,,,,,,,,109.3,,,percent of total billed charges,,,109.3,,,percent of total billed charges,,,,,,,,,101.67,,,percent of total billed charges,,,,,,,,,,,,,,,101.67,,,percent of total billed charges,,,101.67,,,percent of total billed charges,,,101.67,,,percent of total billed charges,,,81.97,,,percent of total billed charges,,,109.3,,,percent of total billed charges,,,109.3,,,percent of total billed charges,,,109.3,,,percent of total billed charges,,,,,,,,,76.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.65,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,64.4,,,percent of total billed charges,,
CLONIDINE-TTS 0.1MG/24HR PATCH,2500009030,CDM,637,RC,378087199,NDC,999,EAPG,,,,outpatient,facility,1,UN,109.3,109.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLONIDINE-TTS 0.2MG/24HR PATCH,2500009032,CDM,637,RC,378087299,NDC,,,,,,inpatient,facility,1,UN,184.04,184.04,14.72,184.04,,,,,,,,,,,,,,184.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.04,,,percent of total billed charges,,,,,,,,,184.04,,,percent of total billed charges,,,93.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.42,,,percent of total billed charges,,,,,,,,,,,,,,,184.04,,,percent of total billed charges,,,156.43,,,percent of total billed charges,,,,,,,,,,,,,,,184.04,,,percent of total billed charges,,,97.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,184.04,,,percent of total billed charges,,,,,,,,,,,,,,,14.72,,,percent of total billed charges,,,184.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,184.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.44,,,percent of total billed charges,,
CLONIDINE-TTS 0.2MG/24HR PATCH,2500009032,CDM,637,RC,378087299,NDC,,,,,,outpatient,facility,1,UN,184.04,184.04,14.72,548.68,,130.5,,,percent of total billed charges,,,44.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,184.04,,,percent of total billed charges,,,115.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,129.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,129.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,184.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,67.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,184.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,184.04,,,fee schedule,,,184.04,,,percent of total billed charges,,,,,,,,,184.04,,,percent of total billed charges,,,112.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.13,,,percent of total billed charges,,,,,,,,,,,,,,,99.38,,,percent of total billed charges,,,95.7,,,percent of total billed charges,,,101.22,,,percent of total billed charges,,,,,,,,,108.58,,,percent of total billed charges,,,548.68,,,per diem,,,184.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,184.04,,,percent of total billed charges,,,156.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,97.74,,,percent of total billed charges,,,184.04,,,percent of total billed charges,,,184.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.15,,,percent of total billed charges,,,148.93,,,percent of total billed charges,,,,,,,,,,,,,,,73.62,,,percent of total billed charges,,,,,,,,,68.09,,,percent of total billed charges,,,68.09,,,percent of total billed charges,,,,,,,,,184.04,,,percent of total billed charges,,,184.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,184.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.72,,,percent of total billed charges,,,184.04,,,percent of total billed charges,,,,,,,,,,,,,,,184.04,,,percent of total billed charges,,,184.04,,,percent of total billed charges,,,,,,,,,171.19,,,percent of total billed charges,,,,,,,,,,,,,,,171.19,,,percent of total billed charges,,,171.19,,,percent of total billed charges,,,171.19,,,percent of total billed charges,,,138.03,,,percent of total billed charges,,,184.04,,,percent of total billed charges,,,184.04,,,percent of total billed charges,,,184.04,,,percent of total billed charges,,,,,,,,,129.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,108.44,,,percent of total billed charges,,
CLONIDINE-TTS 0.2MG/24HR PATCH,2500009032,CDM,637,RC,378087299,NDC,999,EAPG,,,,outpatient,facility,1,UN,184.04,184.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLONIDINE-TTS 0.3MG/24HR PATCH,2500009033,CDM,637,RC,378087399,NDC,,,,,,inpatient,facility,1,UN,255.29,255.29,20.42,255.29,,,,,,,,,,,,,,255.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.29,,,percent of total billed charges,,,,,,,,,255.29,,,percent of total billed charges,,,130.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.17,,,percent of total billed charges,,,,,,,,,,,,,,,255.29,,,percent of total billed charges,,,217,,,percent of total billed charges,,,,,,,,,,,,,,,255.29,,,percent of total billed charges,,,135.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,255.29,,,percent of total billed charges,,,,,,,,,,,,,,,20.42,,,percent of total billed charges,,,255.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,255.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.42,,,percent of total billed charges,,
CLONIDINE-TTS 0.3MG/24HR PATCH,2500009033,CDM,637,RC,378087399,NDC,,,,,,outpatient,facility,1,UN,255.29,255.29,20.42,548.68,,181.03,,,percent of total billed charges,,,62.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,255.29,,,percent of total billed charges,,,159.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,179.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,179.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,255.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,93.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,255.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,255.29,,,fee schedule,,,255.29,,,percent of total billed charges,,,,,,,,,255.29,,,percent of total billed charges,,,156.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.89,,,percent of total billed charges,,,,,,,,,,,,,,,137.86,,,percent of total billed charges,,,132.75,,,percent of total billed charges,,,140.41,,,percent of total billed charges,,,,,,,,,150.62,,,percent of total billed charges,,,548.68,,,per diem,,,255.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,255.29,,,percent of total billed charges,,,217,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,135.58,,,percent of total billed charges,,,255.29,,,percent of total billed charges,,,255.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.22,,,percent of total billed charges,,,206.58,,,percent of total billed charges,,,,,,,,,,,,,,,102.12,,,percent of total billed charges,,,,,,,,,94.46,,,percent of total billed charges,,,94.46,,,percent of total billed charges,,,,,,,,,255.29,,,percent of total billed charges,,,255.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,255.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.42,,,percent of total billed charges,,,255.29,,,percent of total billed charges,,,,,,,,,,,,,,,255.29,,,percent of total billed charges,,,255.29,,,percent of total billed charges,,,,,,,,,237.47,,,percent of total billed charges,,,,,,,,,,,,,,,237.47,,,percent of total billed charges,,,237.47,,,percent of total billed charges,,,237.47,,,percent of total billed charges,,,191.47,,,percent of total billed charges,,,255.29,,,percent of total billed charges,,,255.29,,,percent of total billed charges,,,255.29,,,percent of total billed charges,,,,,,,,,178.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,150.42,,,percent of total billed charges,,
CLONIDINE-TTS 0.3MG/24HR PATCH,2500009033,CDM,637,RC,378087399,NDC,999,EAPG,,,,outpatient,facility,1,UN,255.29,255.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLOPIDOGREL 300 MG TAB,2500009045,CDM,637,RC,904646707,NDC,,,,,,inpatient,facility,300,UN,43.86,43.86,3.51,43.86,,,,,,,,,,,,,,43.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.86,,,percent of total billed charges,,,,,,,,,43.86,,,percent of total billed charges,,,22.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.32,,,percent of total billed charges,,,,,,,,,,,,,,,43.86,,,percent of total billed charges,,,37.28,,,percent of total billed charges,,,,,,,,,,,,,,,43.86,,,percent of total billed charges,,,23.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,43.86,,,percent of total billed charges,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,43.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.84,,,percent of total billed charges,,
CLOPIDOGREL 300 MG TAB,2500009045,CDM,637,RC,904646707,NDC,,,,,,outpatient,facility,300,UN,43.86,43.86,3.51,548.68,,31.1,,,percent of total billed charges,,,10.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,43.86,,,percent of total billed charges,,,27.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,30.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,30.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,43.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,16.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,43.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,43.86,,,fee schedule,,,43.86,,,percent of total billed charges,,,,,,,,,43.86,,,percent of total billed charges,,,26.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.25,,,percent of total billed charges,,,,,,,,,,,,,,,23.68,,,percent of total billed charges,,,22.81,,,percent of total billed charges,,,24.12,,,percent of total billed charges,,,,,,,,,25.88,,,percent of total billed charges,,,548.68,,,per diem,,,43.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,43.86,,,percent of total billed charges,,,37.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.29,,,percent of total billed charges,,,43.86,,,percent of total billed charges,,,43.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.59,,,percent of total billed charges,,,35.49,,,percent of total billed charges,,,,,,,,,,,,,,,17.54,,,percent of total billed charges,,,,,,,,,16.23,,,percent of total billed charges,,,16.23,,,percent of total billed charges,,,,,,,,,43.86,,,percent of total billed charges,,,43.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.51,,,percent of total billed charges,,,43.86,,,percent of total billed charges,,,,,,,,,,,,,,,43.86,,,percent of total billed charges,,,43.86,,,percent of total billed charges,,,,,,,,,40.8,,,percent of total billed charges,,,,,,,,,,,,,,,40.8,,,percent of total billed charges,,,40.8,,,percent of total billed charges,,,40.8,,,percent of total billed charges,,,32.89,,,percent of total billed charges,,,43.86,,,percent of total billed charges,,,43.86,,,percent of total billed charges,,,43.86,,,percent of total billed charges,,,,,,,,,30.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,25.84,,,percent of total billed charges,,
CLOPIDOGREL 300 MG TAB,2500009045,CDM,637,RC,904646707,NDC,999,EAPG,,,,outpatient,facility,300,UN,43.86,43.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLORAZEPATE 3.75 MG TAB,2500009052,CDM,637,RC,5295987360,NDC,,,,,,inpatient,facility,3.75,UN,1.78,1.78,0.14,1.78,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,1.78,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,
CLORAZEPATE 3.75 MG TAB,2500009052,CDM,637,RC,5295987360,NDC,,,,,,outpatient,facility,3.75,UN,1.78,1.78,0.14,548.68,,1.26,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.78,,,percent of total billed charges,,,1.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.78,,,fee schedule,,,1.78,,,percent of total billed charges,,,,,,,,,1.78,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,1.05,,,percent of total billed charges,,,548.68,,,per diem,,,1.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.78,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,1.78,,,percent of total billed charges,,,1.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.14,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.05,,,percent of total billed charges,,
CLORAZEPATE 3.75 MG TAB,2500009052,CDM,637,RC,5295987360,NDC,999,EAPG,,,,outpatient,facility,3.75,UN,1.78,1.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLOTRIMAZOLE 1  CR 30 GM,2500009061,CDM,637,RC,4580243411,NDC,,,,,,inpatient,facility,30,UN,7.64,7.64,0.61,7.64,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,,,,,,,7.64,,,percent of total billed charges,,,3.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,6.49,,,percent of total billed charges,,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,7.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.5,,,percent of total billed charges,,
CLOTRIMAZOLE 1  CR 30 GM,2500009061,CDM,637,RC,4580243411,NDC,,,,,,outpatient,facility,30,UN,7.64,7.64,0.61,548.68,,5.42,,,percent of total billed charges,,,1.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.64,,,percent of total billed charges,,,4.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.8,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.64,,,fee schedule,,,7.64,,,percent of total billed charges,,,,,,,,,7.64,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,3.97,,,percent of total billed charges,,,4.2,,,percent of total billed charges,,,,,,,,,4.51,,,percent of total billed charges,,,548.68,,,per diem,,,7.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.64,,,percent of total billed charges,,,6.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,,7.64,,,percent of total billed charges,,,7.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,6.18,,,percent of total billed charges,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,,,,,,,2.83,,,percent of total billed charges,,,2.83,,,percent of total billed charges,,,,,,,,,7.64,,,percent of total billed charges,,,7.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.61,,,percent of total billed charges,,,7.64,,,percent of total billed charges,,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,7.64,,,percent of total billed charges,,,,,,,,,7.11,,,percent of total billed charges,,,,,,,,,,,,,,,7.11,,,percent of total billed charges,,,7.11,,,percent of total billed charges,,,7.11,,,percent of total billed charges,,,5.73,,,percent of total billed charges,,,7.64,,,percent of total billed charges,,,7.64,,,percent of total billed charges,,,7.64,,,percent of total billed charges,,,,,,,,,5.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.5,,,percent of total billed charges,,
CLOTRIMAZOLE 1  CR 30 GM,2500009061,CDM,637,RC,4580243411,NDC,999,EAPG,,,,outpatient,facility,30,UN,7.64,7.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLOTRIMAZOLE 1  SOLN 30 ML,2500009066,CDM,637,RC,5167212603,NDC,,,,,,inpatient,facility,30,UN,246.61,246.61,19.73,246.61,,,,,,,,,,,,,,246.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,246.61,,,percent of total billed charges,,,,,,,,,246.61,,,percent of total billed charges,,,125.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.97,,,percent of total billed charges,,,,,,,,,,,,,,,246.61,,,percent of total billed charges,,,209.62,,,percent of total billed charges,,,,,,,,,,,,,,,246.61,,,percent of total billed charges,,,130.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,246.61,,,percent of total billed charges,,,,,,,,,,,,,,,19.73,,,percent of total billed charges,,,246.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,246.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.3,,,percent of total billed charges,,
CLOTRIMAZOLE 1  SOLN 30 ML,2500009066,CDM,637,RC,5167212603,NDC,,,,,,outpatient,facility,30,UN,246.61,246.61,19.73,548.68,,174.87,,,percent of total billed charges,,,60.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,246.61,,,percent of total billed charges,,,154.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,173.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,173.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,246.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,90.26,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,246.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,246.61,,,fee schedule,,,246.61,,,percent of total billed charges,,,,,,,,,246.61,,,percent of total billed charges,,,151.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.71,,,percent of total billed charges,,,,,,,,,,,,,,,133.17,,,percent of total billed charges,,,128.24,,,percent of total billed charges,,,135.64,,,percent of total billed charges,,,,,,,,,145.5,,,percent of total billed charges,,,548.68,,,per diem,,,246.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,246.61,,,percent of total billed charges,,,209.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,130.97,,,percent of total billed charges,,,246.61,,,percent of total billed charges,,,246.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.36,,,percent of total billed charges,,,199.56,,,percent of total billed charges,,,,,,,,,,,,,,,98.64,,,percent of total billed charges,,,,,,,,,91.25,,,percent of total billed charges,,,91.25,,,percent of total billed charges,,,,,,,,,246.61,,,percent of total billed charges,,,246.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,246.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.73,,,percent of total billed charges,,,246.61,,,percent of total billed charges,,,,,,,,,,,,,,,246.61,,,percent of total billed charges,,,246.61,,,percent of total billed charges,,,,,,,,,229.4,,,percent of total billed charges,,,,,,,,,,,,,,,229.4,,,percent of total billed charges,,,229.4,,,percent of total billed charges,,,229.4,,,percent of total billed charges,,,184.96,,,percent of total billed charges,,,246.61,,,percent of total billed charges,,,246.61,,,percent of total billed charges,,,246.61,,,percent of total billed charges,,,,,,,,,172.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,145.3,,,percent of total billed charges,,
CLOTRIMAZOLE 1  SOLN 30 ML,2500009066,CDM,637,RC,5167212603,NDC,999,EAPG,,,,outpatient,facility,30,UN,246.61,246.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLOTRIMAZOLE 1  VAG CR 45 GM,2500009067,CDM,637,RC,5167220036,NDC,,,,,,inpatient,facility,45,UN,12,12,0.96,12,,,,,,,,,,,,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12,,,percent of total billed charges,,,,,,,,,12,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.2,,,percent of total billed charges,,,,,,,,,,,,,,,12,,,percent of total billed charges,,,10.2,,,percent of total billed charges,,,,,,,,,,,,,,,12,,,percent of total billed charges,,,6.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.07,,,percent of total billed charges,,
CLOTRIMAZOLE 1  VAG CR 45 GM,2500009067,CDM,637,RC,5167220036,NDC,,,,,,outpatient,facility,45,UN,12,12,0.96,548.68,,8.51,,,percent of total billed charges,,,2.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,12,,,percent of total billed charges,,,7.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.39,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,12,,,fee schedule,,,12,,,percent of total billed charges,,,,,,,,,12,,,percent of total billed charges,,,7.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.55,,,percent of total billed charges,,,,,,,,,,,,,,,6.48,,,percent of total billed charges,,,6.24,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,7.08,,,percent of total billed charges,,,548.68,,,per diem,,,12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12,,,percent of total billed charges,,,10.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.37,,,percent of total billed charges,,,12,,,percent of total billed charges,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.1,,,percent of total billed charges,,,9.71,,,percent of total billed charges,,,,,,,,,,,,,,,4.8,,,percent of total billed charges,,,,,,,,,4.44,,,percent of total billed charges,,,4.44,,,percent of total billed charges,,,,,,,,,12,,,percent of total billed charges,,,12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.96,,,percent of total billed charges,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,12,,,percent of total billed charges,,,12,,,percent of total billed charges,,,,,,,,,11.16,,,percent of total billed charges,,,,,,,,,,,,,,,11.16,,,percent of total billed charges,,,11.16,,,percent of total billed charges,,,11.16,,,percent of total billed charges,,,9,,,percent of total billed charges,,,12,,,percent of total billed charges,,,12,,,percent of total billed charges,,,12,,,percent of total billed charges,,,,,,,,,8.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.07,,,percent of total billed charges,,
CLOTRIMAZOLE 1  VAG CR 45 GM,2500009067,CDM,637,RC,5167220036,NDC,999,EAPG,,,,outpatient,facility,45,UN,12,12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLOTRIMAZOLE 10 MG TROCHE,2500009070,CDM,637,RC,54814622,NDC,,,,,,inpatient,facility,10,UN,11.35,11.35,0.91,11.35,,,,,,,,,,,,,,11.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.35,,,percent of total billed charges,,,,,,,,,11.35,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.81,,,percent of total billed charges,,,,,,,,,,,,,,,11.35,,,percent of total billed charges,,,9.65,,,percent of total billed charges,,,,,,,,,,,,,,,11.35,,,percent of total billed charges,,,6.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,11.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.69,,,percent of total billed charges,,
CLOTRIMAZOLE 10 MG TROCHE,2500009070,CDM,637,RC,54814622,NDC,,,,,,outpatient,facility,10,UN,11.35,11.35,0.91,548.68,,8.05,,,percent of total billed charges,,,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,11.35,,,percent of total billed charges,,,7.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.15,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,11.35,,,fee schedule,,,11.35,,,percent of total billed charges,,,,,,,,,11.35,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,5.9,,,percent of total billed charges,,,6.24,,,percent of total billed charges,,,,,,,,,6.7,,,percent of total billed charges,,,548.68,,,per diem,,,11.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11.35,,,percent of total billed charges,,,9.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.03,,,percent of total billed charges,,,11.35,,,percent of total billed charges,,,11.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,9.18,,,percent of total billed charges,,,,,,,,,,,,,,,4.54,,,percent of total billed charges,,,,,,,,,4.2,,,percent of total billed charges,,,4.2,,,percent of total billed charges,,,,,,,,,11.35,,,percent of total billed charges,,,11.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.91,,,percent of total billed charges,,,11.35,,,percent of total billed charges,,,,,,,,,,,,,,,11.35,,,percent of total billed charges,,,11.35,,,percent of total billed charges,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,8.51,,,percent of total billed charges,,,11.35,,,percent of total billed charges,,,11.35,,,percent of total billed charges,,,11.35,,,percent of total billed charges,,,,,,,,,7.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.67,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.69,,,percent of total billed charges,,
CLOTRIMAZOLE 10 MG TROCHE,2500009070,CDM,637,RC,54814622,NDC,999,EAPG,,,,outpatient,facility,10,UN,11.35,11.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLOZAPINE 100 MG TAB,2500009100,CDM,637,RC,904708761,NDC,,,,,,inpatient,facility,100,UN,3.1,3.1,0.25,3.1,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,3.1,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,
CLOZAPINE 100 MG TAB,2500009100,CDM,637,RC,904708761,NDC,,,,,,outpatient,facility,100,UN,3.1,3.1,0.25,548.68,,2.2,,,percent of total billed charges,,,0.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.1,,,percent of total billed charges,,,1.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.13,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.1,,,fee schedule,,,3.1,,,percent of total billed charges,,,,,,,,,3.1,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,1.83,,,percent of total billed charges,,,548.68,,,per diem,,,3.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.1,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.09,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,,,,,,,1.15,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,3.1,,,percent of total billed charges,,,3.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.25,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,2.88,,,percent of total billed charges,,,,,,,,,,,,,,,2.88,,,percent of total billed charges,,,2.88,,,percent of total billed charges,,,2.88,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.83,,,percent of total billed charges,,
CLOZAPINE 100 MG TAB,2500009100,CDM,637,RC,904708761,NDC,999,EAPG,,,,outpatient,facility,100,UN,3.1,3.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLOZAPINE 25 MG TAB,2500009103,CDM,637,RC,904708961,NDC,,,,,,inpatient,facility,25,UN,1.18,1.18,0.09,1.18,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,
CLOZAPINE 25 MG TAB,2500009103,CDM,637,RC,904708961,NDC,,,,,,outpatient,facility,25,UN,1.18,1.18,0.09,548.68,,0.84,,,percent of total billed charges,,,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.18,,,percent of total billed charges,,,0.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.43,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.18,,,fee schedule,,,1.18,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,0.7,,,percent of total billed charges,,,548.68,,,per diem,,,1.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.18,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,0.44,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,1.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.7,,,percent of total billed charges,,
CLOZAPINE 25 MG TAB,2500009103,CDM,637,RC,904708961,NDC,999,EAPG,,,,outpatient,facility,25,UN,1.18,1.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COCAINE 4  TOP SOLN 4 ML INJ,2500009134,CDM,250,RC,6495036204,NDC,,,,,,inpatient,facility,4,UN,808.5,808.5,64.68,808.5,,,,,,,,,,,,,,808.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,808.5,,,percent of total billed charges,,,,,,,,,808.5,,,percent of total billed charges,,,412.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,688.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,485.1,,,percent of total billed charges,,,,,,,,,,,,,,,808.5,,,percent of total billed charges,,,687.22,,,percent of total billed charges,,,,,,,,,,,,,,,808.5,,,percent of total billed charges,,,429.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,808.5,,,percent of total billed charges,,,,,,,,,,,,,,,64.68,,,percent of total billed charges,,,808.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,808.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.37,,,percent of total billed charges,,
COCAINE 4  TOP SOLN 4 ML INJ,2500009134,CDM,250,RC,6495036204,NDC,,,,,,outpatient,facility,4,UN,808.5,808.5,64.68,808.5,,573.31,,,percent of total billed charges,,,197.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,808.5,,,percent of total billed charges,,,506.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,568.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,568.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,808.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,295.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,808.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,808.5,,,fee schedule,,,808.5,,,percent of total billed charges,,,,,,,,,808.5,,,percent of total billed charges,,,495.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,576.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,477.02,,,percent of total billed charges,,,548.68,,,per diem,,,808.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,808.5,,,percent of total billed charges,,,687.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,429.39,,,percent of total billed charges,,,808.5,,,percent of total billed charges,,,808.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,545.41,,,percent of total billed charges,,,654.24,,,percent of total billed charges,,,,,,,,,,,,,,,323.4,,,percent of total billed charges,,,,,,,,,323.4,,,percent of total billed charges,,,323.4,,,percent of total billed charges,,,,,,,,,808.5,,,percent of total billed charges,,,808.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,808.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,64.68,,,percent of total billed charges,,,808.5,,,percent of total billed charges,,,,,,,,,,,,,,,808.5,,,percent of total billed charges,,,808.5,,,percent of total billed charges,,,,,,,,,323.4,,,percent of total billed charges,,,,,,,,,,,,,,,323.4,,,percent of total billed charges,,,323.4,,,percent of total billed charges,,,323.4,,,percent of total billed charges,,,606.38,,,percent of total billed charges,,,808.5,,,percent of total billed charges,,,808.5,,,percent of total billed charges,,,808.5,,,percent of total billed charges,,,,,,,,,566.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,476.37,,,percent of total billed charges,,
COCAINE 4  TOP SOLN 4 ML INJ,2500009134,CDM,250,RC,6495036204,NDC,999,EAPG,,,,outpatient,facility,4,UN,808.5,808.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CODEINE SULF 30 MG TAB,2500009173,CDM,637,RC,54024425,NDC,,,,,,inpatient,facility,30,UN,3.07,3.07,0.25,3.07,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,3.07,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,
CODEINE SULF 30 MG TAB,2500009173,CDM,637,RC,54024425,NDC,,,,,,outpatient,facility,30,UN,3.07,3.07,0.25,548.68,,2.18,,,percent of total billed charges,,,0.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.07,,,percent of total billed charges,,,1.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.12,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.07,,,fee schedule,,,3.07,,,percent of total billed charges,,,,,,,,,3.07,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,1.69,,,percent of total billed charges,,,,,,,,,1.81,,,percent of total billed charges,,,548.68,,,per diem,,,3.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.07,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.07,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,1.14,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,3.07,,,percent of total billed charges,,,3.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.25,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,2.86,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.81,,,percent of total billed charges,,
CODEINE SULF 30 MG TAB,2500009173,CDM,637,RC,54024425,NDC,999,EAPG,,,,outpatient,facility,30,UN,3.07,3.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COLCHICINE 0.6 MG TAB,2500009183,CDM,637,RC,7071013513,NDC,,,,,,inpatient,facility,0.6,UN,22.24,22.24,1.78,22.24,,,,,,,,,,,,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.24,,,percent of total billed charges,,,,,,,,,22.24,,,percent of total billed charges,,,11.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.34,,,percent of total billed charges,,,,,,,,,,,,,,,22.24,,,percent of total billed charges,,,18.9,,,percent of total billed charges,,,,,,,,,,,,,,,22.24,,,percent of total billed charges,,,11.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,
COLCHICINE 0.6 MG TAB,2500009183,CDM,637,RC,7071013513,NDC,,,,,,outpatient,facility,0.6,UN,22.24,22.24,1.78,548.68,,15.77,,,percent of total billed charges,,,5.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,22.24,,,percent of total billed charges,,,13.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,15.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,15.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.14,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,22.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,22.24,,,fee schedule,,,22.24,,,percent of total billed charges,,,,,,,,,22.24,,,percent of total billed charges,,,13.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.85,,,percent of total billed charges,,,,,,,,,,,,,,,12.01,,,percent of total billed charges,,,11.56,,,percent of total billed charges,,,12.23,,,percent of total billed charges,,,,,,,,,13.12,,,percent of total billed charges,,,548.68,,,per diem,,,22.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,22.24,,,percent of total billed charges,,,18.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.81,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15,,,percent of total billed charges,,,18,,,percent of total billed charges,,,,,,,,,,,,,,,8.9,,,percent of total billed charges,,,,,,,,,8.23,,,percent of total billed charges,,,8.23,,,percent of total billed charges,,,,,,,,,22.24,,,percent of total billed charges,,,22.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.78,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,22.24,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,,,,,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,16.68,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,,,,,,,15.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.1,,,percent of total billed charges,,
COLCHICINE 0.6 MG TAB,2500009183,CDM,637,RC,7071013513,NDC,999,EAPG,,,,outpatient,facility,0.6,UN,22.24,22.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COLESTIPOL HCL 1 GM TAB,2500009190,CDM,637,RC,115521116,NDC,,,,,,inpatient,facility,1,UN,4.09,4.09,0.33,4.09,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,4.09,,,percent of total billed charges,,,2.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,3.48,,,percent of total billed charges,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,
COLESTIPOL HCL 1 GM TAB,2500009190,CDM,637,RC,115521116,NDC,,,,,,outpatient,facility,1,UN,4.09,4.09,0.33,548.68,,2.9,,,percent of total billed charges,,,1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.09,,,percent of total billed charges,,,2.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.5,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.09,,,fee schedule,,,4.09,,,percent of total billed charges,,,,,,,,,4.09,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,2.25,,,percent of total billed charges,,,,,,,,,2.41,,,percent of total billed charges,,,548.68,,,per diem,,,4.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.09,,,percent of total billed charges,,,3.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,,,,,,,,1.51,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,4.09,,,percent of total billed charges,,,4.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.33,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.41,,,percent of total billed charges,,
COLESTIPOL HCL 1 GM TAB,2500009190,CDM,637,RC,115521116,NDC,999,EAPG,,,,outpatient,facility,1,UN,4.09,4.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COLLAGENASE OINT 30 GM,2500009213,CDM,637,RC,5048401030,NDC,,,,,,inpatient,facility,30,UN,997.76,997.76,79.82,997.76,,,,,,,,,,,,,,997.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.76,,,percent of total billed charges,,,,,,,,,997.76,,,percent of total billed charges,,,509.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,849.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,598.66,,,percent of total billed charges,,,,,,,,,,,,,,,997.76,,,percent of total billed charges,,,848.1,,,percent of total billed charges,,,,,,,,,,,,,,,997.76,,,percent of total billed charges,,,529.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,399.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,997.76,,,percent of total billed charges,,,,,,,,,,,,,,,79.82,,,percent of total billed charges,,,997.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,997.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,587.88,,,percent of total billed charges,,
COLLAGENASE OINT 30 GM,2500009213,CDM,637,RC,5048401030,NDC,,,,,,outpatient,facility,30,UN,997.76,997.76,79.82,997.76,,707.51,,,percent of total billed charges,,,243.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,997.76,,,percent of total billed charges,,,625.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,701.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,701.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,997.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,365.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,997.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,997.76,,,fee schedule,,,997.76,,,percent of total billed charges,,,,,,,,,997.76,,,percent of total billed charges,,,611.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,710.9,,,percent of total billed charges,,,,,,,,,,,,,,,538.79,,,percent of total billed charges,,,518.84,,,percent of total billed charges,,,548.77,,,percent of total billed charges,,,,,,,,,588.68,,,percent of total billed charges,,,548.68,,,per diem,,,997.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,997.76,,,percent of total billed charges,,,848.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,529.91,,,percent of total billed charges,,,997.76,,,percent of total billed charges,,,997.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,673.09,,,percent of total billed charges,,,807.39,,,percent of total billed charges,,,,,,,,,,,,,,,399.1,,,percent of total billed charges,,,,,,,,,369.17,,,percent of total billed charges,,,369.17,,,percent of total billed charges,,,,,,,,,997.76,,,percent of total billed charges,,,997.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,997.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,79.82,,,percent of total billed charges,,,997.76,,,percent of total billed charges,,,,,,,,,,,,,,,997.76,,,percent of total billed charges,,,997.76,,,percent of total billed charges,,,,,,,,,928.12,,,percent of total billed charges,,,,,,,,,,,,,,,928.12,,,percent of total billed charges,,,928.12,,,percent of total billed charges,,,928.12,,,percent of total billed charges,,,748.32,,,percent of total billed charges,,,997.76,,,percent of total billed charges,,,997.76,,,percent of total billed charges,,,997.76,,,percent of total billed charges,,,,,,,,,699.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,587.88,,,percent of total billed charges,,
COLLAGENASE OINT 30 GM,2500009213,CDM,637,RC,5048401030,NDC,999,EAPG,,,,outpatient,facility,30,UN,997.76,997.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CORTISONE ACETATE 5 MG TAB,2500009264,CDM,637,RC,5976200731,NDC,,,,,,inpatient,facility,5,UN,0.56,0.56,0.04,0.56,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,
CORTISONE ACETATE 5 MG TAB,2500009264,CDM,637,RC,5976200731,NDC,,,,,,outpatient,facility,5,UN,0.56,0.56,0.04,548.68,,0.4,,,percent of total billed charges,,,0.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,0.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.2,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.56,,,fee schedule,,,0.56,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,0.33,,,percent of total billed charges,,,548.68,,,per diem,,,0.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.56,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.33,,,percent of total billed charges,,
CORTISONE ACETATE 5 MG TAB,2500009264,CDM,637,RC,5976200731,NDC,999,EAPG,,,,outpatient,facility,5,UN,0.56,0.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CROMOLYN  SOD 4  OPH 10 ML,2500009314,CDM,637,RC,6131423710,NDC,,,,,,inpatient,facility,10,UN,122.76,122.76,9.82,122.76,,,,,,,,,,,,,,122.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.76,,,percent of total billed charges,,,,,,,,,122.76,,,percent of total billed charges,,,62.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.66,,,percent of total billed charges,,,,,,,,,,,,,,,122.76,,,percent of total billed charges,,,104.35,,,percent of total billed charges,,,,,,,,,,,,,,,122.76,,,percent of total billed charges,,,65.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,122.76,,,percent of total billed charges,,,,,,,,,,,,,,,9.82,,,percent of total billed charges,,,122.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,122.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.33,,,percent of total billed charges,,
CROMOLYN  SOD 4  OPH 10 ML,2500009314,CDM,637,RC,6131423710,NDC,,,,,,outpatient,facility,10,UN,122.76,122.76,9.82,548.68,,87.05,,,percent of total billed charges,,,29.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,122.76,,,percent of total billed charges,,,76.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,86.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,86.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,122.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,44.93,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,122.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,122.76,,,fee schedule,,,122.76,,,percent of total billed charges,,,,,,,,,122.76,,,percent of total billed charges,,,75.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.47,,,percent of total billed charges,,,,,,,,,,,,,,,66.29,,,percent of total billed charges,,,63.84,,,percent of total billed charges,,,67.52,,,percent of total billed charges,,,,,,,,,72.43,,,percent of total billed charges,,,548.68,,,per diem,,,122.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,122.76,,,percent of total billed charges,,,104.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.2,,,percent of total billed charges,,,122.76,,,percent of total billed charges,,,122.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,99.34,,,percent of total billed charges,,,,,,,,,,,,,,,49.1,,,percent of total billed charges,,,,,,,,,45.42,,,percent of total billed charges,,,45.42,,,percent of total billed charges,,,,,,,,,122.76,,,percent of total billed charges,,,122.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,122.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.82,,,percent of total billed charges,,,122.76,,,percent of total billed charges,,,,,,,,,,,,,,,122.76,,,percent of total billed charges,,,122.76,,,percent of total billed charges,,,,,,,,,114.19,,,percent of total billed charges,,,,,,,,,,,,,,,114.19,,,percent of total billed charges,,,114.19,,,percent of total billed charges,,,114.19,,,percent of total billed charges,,,92.07,,,percent of total billed charges,,,122.76,,,percent of total billed charges,,,122.76,,,percent of total billed charges,,,122.76,,,percent of total billed charges,,,,,,,,,86.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,72.33,,,percent of total billed charges,,
CROMOLYN  SOD 4  OPH 10 ML,2500009314,CDM,637,RC,6131423710,NDC,999,EAPG,,,,outpatient,facility,10,UN,122.76,122.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CYANOCOBALAMIN 500 MCG TAB,2500009355,CDM,637,RC,7733393710,NDC,,,,,,inpatient,facility,500,UN,1.25,1.25,0.1,1.25,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,
CYANOCOBALAMIN 500 MCG TAB,2500009355,CDM,637,RC,7733393710,NDC,,,,,,outpatient,facility,500,UN,1.25,1.25,0.1,548.68,,0.89,,,percent of total billed charges,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.25,,,percent of total billed charges,,,0.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.25,,,fee schedule,,,1.25,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,548.68,,,per diem,,,1.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.25,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.74,,,percent of total billed charges,,
CYANOCOBALAMIN 500 MCG TAB,2500009355,CDM,637,RC,7733393710,NDC,999,EAPG,,,,outpatient,facility,500,UN,1.25,1.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CYCLOBENZAPRINE 10 MG TAB,2500009370,CDM,637,RC,6909784607,NDC,,,,,,inpatient,facility,10,UN,3.83,3.83,0.31,3.83,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,3.83,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,
CYCLOBENZAPRINE 10 MG TAB,2500009370,CDM,637,RC,6909784607,NDC,,,,,,outpatient,facility,10,UN,3.83,3.83,0.31,548.68,,2.72,,,percent of total billed charges,,,0.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.83,,,percent of total billed charges,,,2.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.83,,,fee schedule,,,3.83,,,percent of total billed charges,,,,,,,,,3.83,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,2.07,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,2.26,,,percent of total billed charges,,,548.68,,,per diem,,,3.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.83,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,3.83,,,percent of total billed charges,,,3.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.31,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,,,,,,,2.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.26,,,percent of total billed charges,,
CYCLOBENZAPRINE 10 MG TAB,2500009370,CDM,637,RC,6909784607,NDC,999,EAPG,,,,outpatient,facility,10,UN,3.83,3.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CYCLOPENTOLATE 1  OP 2 ML DRPT,2500009386,CDM,637,RC,6131439601,NDC,,,,,,inpatient,facility,2,UN,55.44,55.44,4.44,55.44,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,55.44,,,percent of total billed charges,,,28.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.26,,,percent of total billed charges,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,47.12,,,percent of total billed charges,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,29.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,4.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.67,,,percent of total billed charges,,
CYCLOPENTOLATE 1  OP 2 ML DRPT,2500009386,CDM,637,RC,6131439601,NDC,,,,,,outpatient,facility,2,UN,55.44,55.44,4.44,548.68,,39.31,,,percent of total billed charges,,,13.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,55.44,,,percent of total billed charges,,,34.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,38.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,38.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,20.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,55.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,55.44,,,fee schedule,,,55.44,,,percent of total billed charges,,,,,,,,,55.44,,,percent of total billed charges,,,33.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.5,,,percent of total billed charges,,,,,,,,,,,,,,,29.94,,,percent of total billed charges,,,28.83,,,percent of total billed charges,,,30.49,,,percent of total billed charges,,,,,,,,,32.71,,,percent of total billed charges,,,548.68,,,per diem,,,55.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,55.44,,,percent of total billed charges,,,47.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.4,,,percent of total billed charges,,,44.86,,,percent of total billed charges,,,,,,,,,,,,,,,22.18,,,percent of total billed charges,,,,,,,,,20.51,,,percent of total billed charges,,,20.51,,,percent of total billed charges,,,,,,,,,55.44,,,percent of total billed charges,,,55.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,55.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,51.57,,,percent of total billed charges,,,,,,,,,,,,,,,51.57,,,percent of total billed charges,,,51.57,,,percent of total billed charges,,,51.57,,,percent of total billed charges,,,41.58,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,38.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,32.67,,,percent of total billed charges,,
CYCLOPENTOLATE 1  OP 2 ML DRPT,2500009386,CDM,637,RC,6131439601,NDC,999,EAPG,,,,outpatient,facility,2,UN,55.44,55.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CYCLOPENTOLATE/PHENY OP 2 ML,2500009390,CDM,637,RC,65035902,NDC,,,,,,inpatient,facility,2,UN,116.36,116.36,9.31,116.36,,,,,,,,,,,,,,116.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.36,,,percent of total billed charges,,,,,,,,,116.36,,,percent of total billed charges,,,59.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.82,,,percent of total billed charges,,,,,,,,,,,,,,,116.36,,,percent of total billed charges,,,98.91,,,percent of total billed charges,,,,,,,,,,,,,,,116.36,,,percent of total billed charges,,,61.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,116.36,,,percent of total billed charges,,,,,,,,,,,,,,,9.31,,,percent of total billed charges,,,116.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,116.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.56,,,percent of total billed charges,,
CYCLOPENTOLATE/PHENY OP 2 ML,2500009390,CDM,637,RC,65035902,NDC,,,,,,outpatient,facility,2,UN,116.36,116.36,9.31,548.68,,82.51,,,percent of total billed charges,,,28.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,116.36,,,percent of total billed charges,,,72.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,81.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,81.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,116.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,42.59,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,116.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,116.36,,,fee schedule,,,116.36,,,percent of total billed charges,,,,,,,,,116.36,,,percent of total billed charges,,,71.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.91,,,percent of total billed charges,,,,,,,,,,,,,,,62.83,,,percent of total billed charges,,,60.51,,,percent of total billed charges,,,64,,,percent of total billed charges,,,,,,,,,68.65,,,percent of total billed charges,,,548.68,,,per diem,,,116.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,116.36,,,percent of total billed charges,,,98.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.8,,,percent of total billed charges,,,116.36,,,percent of total billed charges,,,116.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.5,,,percent of total billed charges,,,94.16,,,percent of total billed charges,,,,,,,,,,,,,,,46.54,,,percent of total billed charges,,,,,,,,,43.05,,,percent of total billed charges,,,43.05,,,percent of total billed charges,,,,,,,,,116.36,,,percent of total billed charges,,,116.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,116.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.31,,,percent of total billed charges,,,116.36,,,percent of total billed charges,,,,,,,,,,,,,,,116.36,,,percent of total billed charges,,,116.36,,,percent of total billed charges,,,,,,,,,108.24,,,percent of total billed charges,,,,,,,,,,,,,,,108.24,,,percent of total billed charges,,,108.24,,,percent of total billed charges,,,108.24,,,percent of total billed charges,,,87.27,,,percent of total billed charges,,,116.36,,,percent of total billed charges,,,116.36,,,percent of total billed charges,,,116.36,,,percent of total billed charges,,,,,,,,,81.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,68.56,,,percent of total billed charges,,
CYCLOPENTOLATE/PHENY OP 2 ML,2500009390,CDM,637,RC,65035902,NDC,999,EAPG,,,,outpatient,facility,2,UN,116.36,116.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CYPROHEPTADINE 4 MG TAB,2500009430,CDM,637,RC,5281721010,NDC,,,,,,inpatient,facility,4,UN,3.53,3.53,0.28,3.53,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,3.53,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,
CYPROHEPTADINE 4 MG TAB,2500009430,CDM,637,RC,5281721010,NDC,,,,,,outpatient,facility,4,UN,3.53,3.53,0.28,548.68,,2.5,,,percent of total billed charges,,,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.53,,,percent of total billed charges,,,2.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.53,,,fee schedule,,,3.53,,,percent of total billed charges,,,,,,,,,3.53,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,548.68,,,per diem,,,3.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.53,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,1.31,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,3.53,,,percent of total billed charges,,,3.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,3.28,,,percent of total billed charges,,,3.28,,,percent of total billed charges,,,3.28,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.08,,,percent of total billed charges,,
CYPROHEPTADINE 4 MG TAB,2500009430,CDM,637,RC,5281721010,NDC,999,EAPG,,,,outpatient,facility,4,UN,3.53,3.53,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W-LACTATED RINGERS 500 ML,2500009446,CDM,258,RC,J7121,HCPCS,338012503,NDC,,,,inpatient,facility,500,UN,19.77,19.77,1.58,19.77,,,,,,,,,,,,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.77,,,percent of total billed charges,,,,,,,,,19.77,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.86,,,percent of total billed charges,,,,,,,,,,,,,,,19.77,,,percent of total billed charges,,,16.8,,,percent of total billed charges,,,,,,,,,,,,,,,19.77,,,percent of total billed charges,,,10.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.65,,,percent of total billed charges,,
D5W-LACTATED RINGERS 500 ML,2500009446,CDM,258,RC,J7121,HCPCS,338012503,NDC,,,,outpatient,facility,500,UN,19.77,19.77,1.58,548.68,,14.02,,,percent of total billed charges,,,4.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,19.77,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.24,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,19.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,19.77,,,fee schedule,,,19.77,,,percent of total billed charges,,,,,,,,,19.77,,,percent of total billed charges,,,12.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,11.66,,,percent of total billed charges,,,548.68,,,per diem,,,19.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,19.77,,,percent of total billed charges,,,16.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.5,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.34,,,percent of total billed charges,,,16,,,percent of total billed charges,,,,,,,,,,,,,,,7.91,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,19.77,,,percent of total billed charges,,,19.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.58,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,,19.77,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,14.83,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,19.77,,,percent of total billed charges,,,,,,,,,13.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.65,,,percent of total billed charges,,
D5W-LACTATED RINGERS 500 ML,2500009446,CDM,258,RC,J7121,HCPCS,338012503,NDC,999,EAPG,,outpatient,facility,500,UN,19.77,19.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W/0.225  NS KCL 20MEQ 1000ML,2500009453,CDM,258,RC,990790109,NDC,,,,,,inpatient,facility,1000,UN,33,33,2.64,33,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,16.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,17.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.44,,,percent of total billed charges,,
D5W/0.225  NS KCL 20MEQ 1000ML,2500009453,CDM,258,RC,990790109,NDC,,,,,,outpatient,facility,1000,UN,33,33,2.64,548.68,,23.4,,,percent of total billed charges,,,8.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,33,,,percent of total billed charges,,,20.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,23.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,23.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,33,,,fee schedule,,,33,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,20.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,19.47,,,percent of total billed charges,,,548.68,,,per diem,,,33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,33,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.53,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.26,,,percent of total billed charges,,,26.7,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.64,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,23.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,19.44,,,percent of total billed charges,,
D5W/0.225  NS KCL 20MEQ 1000ML,2500009453,CDM,258,RC,990790109,NDC,999,EAPG,,,,outpatient,facility,1000,UN,33,33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHL 0.9 KCL 40MEQ 1000ML,2500009455,CDM,636,RC,J3480,HCPCS,990711609,NDC,,,,inpatient,facility,1000,UN,29.63,29.63,2.37,29.63,,,,,,,,,,,,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.63,,,percent of total billed charges,,,,,,,,,29.63,,,percent of total billed charges,,,15.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.78,,,percent of total billed charges,,,,,,,,,,,,,,,29.63,,,percent of total billed charges,,,25.19,,,percent of total billed charges,,,,,,,,,,,,,,,29.63,,,percent of total billed charges,,,15.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.46,,,percent of total billed charges,,
SOD CHL 0.9 KCL 40MEQ 1000ML,2500009455,CDM,636,RC,J3480,HCPCS,990711609,NDC,,,,outpatient,facility,1000,UN,29.63,29.63,0.11,548.68,,21.01,,,percent of total billed charges,,,7.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,29.63,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.84,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,29.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,29.63,,,fee schedule,,,29.63,,,percent of total billed charges,,,,,,,,,29.63,,,percent of total billed charges,,,18.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,17.48,,,percent of total billed charges,,,548.68,,,per diem,,,29.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,29.63,,,percent of total billed charges,,,25.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.74,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.99,,,percent of total billed charges,,,23.98,,,percent of total billed charges,,,,,,,,,,,,,,,11.85,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,29.63,,,percent of total billed charges,,,29.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.37,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,29.63,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,29.63,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.46,,,percent of total billed charges,,
SOD CHL 0.9 KCL 40MEQ 1000ML,2500009455,CDM,636,RC,J3480,HCPCS,990711609,NDC,999,EAPG,,outpatient,facility,1000,UN,29.63,29.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W KCL 40 MEQ 1000 ML,2500009456,CDM,636,RC,J3480,HCPCS,409790609,NDC,,,,inpatient,facility,1000,UN,9.14,9.14,0.73,9.14,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,,,,,,,9.14,,,percent of total billed charges,,,4.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,7.77,,,percent of total billed charges,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,4.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.39,,,percent of total billed charges,,
D5W KCL 40 MEQ 1000 ML,2500009456,CDM,636,RC,J3480,HCPCS,409790609,NDC,,,,outpatient,facility,1000,UN,9.14,9.14,0.11,548.68,,6.48,,,percent of total billed charges,,,2.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.14,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.35,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.14,,,fee schedule,,,9.14,,,percent of total billed charges,,,,,,,,,9.14,,,percent of total billed charges,,,5.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,5.39,,,percent of total billed charges,,,548.68,,,per diem,,,9.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.14,,,percent of total billed charges,,,7.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.85,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.17,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,3.66,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9.14,,,percent of total billed charges,,,9.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.73,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,9.14,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,,,,,,,6.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.39,,,percent of total billed charges,,
D5W KCL 40 MEQ 1000 ML,2500009456,CDM,636,RC,J3480,HCPCS,409790609,NDC,999,EAPG,,outpatient,facility,1000,UN,9.14,9.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W KCL 20 MEQ 1000 ML,2500009457,CDM,636,RC,J3480,HCPCS,990790509,NDC,,,,inpatient,facility,1000,UN,25.18,25.18,2.01,25.18,,,,,,,,,,,,,,25.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.18,,,percent of total billed charges,,,,,,,,,25.18,,,percent of total billed charges,,,12.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.11,,,percent of total billed charges,,,,,,,,,,,,,,,25.18,,,percent of total billed charges,,,21.4,,,percent of total billed charges,,,,,,,,,,,,,,,25.18,,,percent of total billed charges,,,13.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,25.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,25.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.84,,,percent of total billed charges,,
D5W KCL 20 MEQ 1000 ML,2500009457,CDM,636,RC,J3480,HCPCS,990790509,NDC,,,,outpatient,facility,1000,UN,25.18,25.18,0.11,548.68,,17.86,,,percent of total billed charges,,,6.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,25.18,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,25.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,25.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,25.18,,,fee schedule,,,25.18,,,percent of total billed charges,,,,,,,,,25.18,,,percent of total billed charges,,,15.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,14.86,,,percent of total billed charges,,,548.68,,,per diem,,,25.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,25.18,,,percent of total billed charges,,,21.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,,25.18,,,percent of total billed charges,,,25.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.99,,,percent of total billed charges,,,20.38,,,percent of total billed charges,,,,,,,,,,,,,,,10.07,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,25.18,,,percent of total billed charges,,,25.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.01,,,percent of total billed charges,,,25.18,,,percent of total billed charges,,,,,,,,,,,,,,,25.18,,,percent of total billed charges,,,25.18,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,25.18,,,percent of total billed charges,,,25.18,,,percent of total billed charges,,,25.18,,,percent of total billed charges,,,,,,,,,17.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.84,,,percent of total billed charges,,
D5W KCL 20 MEQ 1000 ML,2500009457,CDM,636,RC,J3480,HCPCS,990790509,NDC,999,EAPG,,outpatient,facility,1000,UN,25.18,25.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHL 0.9 KCL 20MEQ 1000ML,2500009458,CDM,636,RC,J3480,HCPCS,264786500,NDC,,,,inpatient,facility,1000,ML,16.56,16.56,1.32,16.56,,,,,,,,,,,,,,16.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.56,,,percent of total billed charges,,,,,,,,,16.56,,,percent of total billed charges,,,8.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.94,,,percent of total billed charges,,,,,,,,,,,,,,,16.56,,,percent of total billed charges,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,16.56,,,percent of total billed charges,,,8.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,16.56,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,16.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.76,,,percent of total billed charges,,
SOD CHL 0.9 KCL 20MEQ 1000ML,2500009458,CDM,636,RC,J3480,HCPCS,264786500,NDC,,,,outpatient,facility,1000,ML,16.56,16.56,0.11,548.68,,11.74,,,percent of total billed charges,,,4.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,16.56,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,16.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.06,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,16.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,16.56,,,fee schedule,,,16.56,,,percent of total billed charges,,,,,,,,,16.56,,,percent of total billed charges,,,10.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,9.77,,,percent of total billed charges,,,548.68,,,per diem,,,16.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,16.56,,,percent of total billed charges,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.8,,,percent of total billed charges,,,16.56,,,percent of total billed charges,,,16.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.17,,,percent of total billed charges,,,13.4,,,percent of total billed charges,,,,,,,,,,,,,,,6.62,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,16.56,,,percent of total billed charges,,,16.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.32,,,percent of total billed charges,,,16.56,,,percent of total billed charges,,,,,,,,,,,,,,,16.56,,,percent of total billed charges,,,16.56,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,16.56,,,percent of total billed charges,,,16.56,,,percent of total billed charges,,,16.56,,,percent of total billed charges,,,,,,,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.76,,,percent of total billed charges,,
SOD CHL 0.9 KCL 20MEQ 1000ML,2500009458,CDM,636,RC,J3480,HCPCS,264786500,NDC,999,EAPG,,outpatient,facility,1000,ML,16.56,16.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W/0.9  NS KCL 40MEQ 1000ML,2500009459,CDM,636,RC,J3480,HCPCS,338080704,NDC,,,,inpatient,facility,1000,UN,29.77,29.77,2.38,29.77,,,,,,,,,,,,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.77,,,percent of total billed charges,,,,,,,,,29.77,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.86,,,percent of total billed charges,,,,,,,,,,,,,,,29.77,,,percent of total billed charges,,,25.3,,,percent of total billed charges,,,,,,,,,,,,,,,29.77,,,percent of total billed charges,,,15.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.54,,,percent of total billed charges,,
D5W/0.9  NS KCL 40MEQ 1000ML,2500009459,CDM,636,RC,J3480,HCPCS,338080704,NDC,,,,outpatient,facility,1000,UN,29.77,29.77,0.11,548.68,,21.11,,,percent of total billed charges,,,7.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,29.77,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.9,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,29.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,29.77,,,fee schedule,,,29.77,,,percent of total billed charges,,,,,,,,,29.77,,,percent of total billed charges,,,18.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,17.56,,,percent of total billed charges,,,548.68,,,per diem,,,29.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,29.77,,,percent of total billed charges,,,25.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.81,,,percent of total billed charges,,,29.77,,,percent of total billed charges,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.08,,,percent of total billed charges,,,24.09,,,percent of total billed charges,,,,,,,,,,,,,,,11.91,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,29.77,,,percent of total billed charges,,,29.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.38,,,percent of total billed charges,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,,29.77,,,percent of total billed charges,,,29.77,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,29.77,,,percent of total billed charges,,,29.77,,,percent of total billed charges,,,29.77,,,percent of total billed charges,,,,,,,,,20.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.54,,,percent of total billed charges,,
D5W/0.9  NS KCL 40MEQ 1000ML,2500009459,CDM,636,RC,J3480,HCPCS,338080704,NDC,999,EAPG,,outpatient,facility,1000,UN,29.77,29.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W/0.45 NS KCL 20 MEQ 1000ML,2500009461,CDM,636,RC,J3480,HCPCS,990790209,NDC,,,,inpatient,facility,1000,ML,24.45,24.45,1.96,24.45,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,24.45,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.67,,,percent of total billed charges,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,20.78,,,percent of total billed charges,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,12.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.41,,,percent of total billed charges,,
D5W/0.45 NS KCL 20 MEQ 1000ML,2500009461,CDM,636,RC,J3480,HCPCS,990790209,NDC,,,,outpatient,facility,1000,ML,24.45,24.45,0.11,548.68,,17.34,,,percent of total billed charges,,,5.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,24.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.95,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,24.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,24.45,,,fee schedule,,,24.45,,,percent of total billed charges,,,,,,,,,24.45,,,percent of total billed charges,,,14.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,14.43,,,percent of total billed charges,,,548.68,,,per diem,,,24.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,24.45,,,percent of total billed charges,,,20.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.99,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.49,,,percent of total billed charges,,,19.78,,,percent of total billed charges,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,24.45,,,percent of total billed charges,,,24.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.96,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,17.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.41,,,percent of total billed charges,,
D5W/0.45 NS KCL 20 MEQ 1000ML,2500009461,CDM,636,RC,J3480,HCPCS,990790209,NDC,999,EAPG,,outpatient,facility,1000,ML,24.45,24.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W/0.45  NS KCL 40MEQ 1000ML,2500009464,CDM,636,RC,J3480,HCPCS,990790409,NDC,,,,inpatient,facility,1000,UN,24.45,24.45,1.96,24.45,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,24.45,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.67,,,percent of total billed charges,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,20.78,,,percent of total billed charges,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,12.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.41,,,percent of total billed charges,,
D5W/0.45  NS KCL 40MEQ 1000ML,2500009464,CDM,636,RC,J3480,HCPCS,990790409,NDC,,,,outpatient,facility,1000,UN,24.45,24.45,0.11,548.68,,17.34,,,percent of total billed charges,,,5.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,24.45,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.95,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,24.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,24.45,,,fee schedule,,,24.45,,,percent of total billed charges,,,,,,,,,24.45,,,percent of total billed charges,,,14.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,14.43,,,percent of total billed charges,,,548.68,,,per diem,,,24.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,24.45,,,percent of total billed charges,,,20.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.99,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.49,,,percent of total billed charges,,,19.78,,,percent of total billed charges,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,24.45,,,percent of total billed charges,,,24.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.96,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,24.45,,,percent of total billed charges,,,,,,,,,17.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.41,,,percent of total billed charges,,
D5W/0.45  NS KCL 40MEQ 1000ML,2500009464,CDM,636,RC,J3480,HCPCS,990790409,NDC,999,EAPG,,outpatient,facility,1000,UN,24.45,24.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W/0.9  NS KCL 20MEQ 1000ML,2500009466,CDM,636,RC,J3480,HCPCS,264765200,NDC,,,,inpatient,facility,1000,UN,16.9,16.9,1.35,16.9,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,,,,,,,16.9,,,percent of total billed charges,,,8.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.14,,,percent of total billed charges,,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,14.36,,,percent of total billed charges,,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.96,,,percent of total billed charges,,
D5W/0.9  NS KCL 20MEQ 1000ML,2500009466,CDM,636,RC,J3480,HCPCS,264765200,NDC,,,,outpatient,facility,1000,UN,16.9,16.9,0.11,548.68,,11.98,,,percent of total billed charges,,,4.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,16.9,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.19,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,16.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,16.9,,,fee schedule,,,16.9,,,percent of total billed charges,,,,,,,,,16.9,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,9.97,,,percent of total billed charges,,,548.68,,,per diem,,,16.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,16.9,,,percent of total billed charges,,,14.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.98,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.4,,,percent of total billed charges,,,13.68,,,percent of total billed charges,,,,,,,,,,,,,,,6.76,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,16.9,,,percent of total billed charges,,,16.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.35,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,,16.9,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,16.9,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,,,,,,,11.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.96,,,percent of total billed charges,,
D5W/0.9  NS KCL 20MEQ 1000ML,2500009466,CDM,636,RC,J3480,HCPCS,264765200,NDC,999,EAPG,,outpatient,facility,1000,UN,16.9,16.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W-LACTATED RINGERS 1000 ML,2500009467,CDM,258,RC,J7121,HCPCS,338012504,NDC,,,,inpatient,facility,1000,UN,10.36,10.36,0.83,10.36,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,,,,,,,10.36,,,percent of total billed charges,,,5.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.22,,,percent of total billed charges,,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,5.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.1,,,percent of total billed charges,,
D5W-LACTATED RINGERS 1000 ML,2500009467,CDM,258,RC,J7121,HCPCS,338012504,NDC,,,,outpatient,facility,1000,UN,10.36,10.36,0.83,548.68,,7.35,,,percent of total billed charges,,,2.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.36,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.79,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.36,,,fee schedule,,,10.36,,,percent of total billed charges,,,,,,,,,10.36,,,percent of total billed charges,,,6.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,6.11,,,percent of total billed charges,,,548.68,,,per diem,,,10.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.36,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.5,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.99,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,4.14,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10.36,,,percent of total billed charges,,,10.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.83,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,7.77,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,,,,,,,7.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.1,,,percent of total billed charges,,
D5W-LACTATED RINGERS 1000 ML,2500009467,CDM,258,RC,J7121,HCPCS,338012504,NDC,999,EAPG,,outpatient,facility,1000,UN,10.36,10.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DAPSONE 25 MG TAB,2500009513,CDM,637,RC,7095413510,NDC,,,,,,inpatient,facility,25,UN,8.15,8.15,0.65,8.15,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,8.15,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,4.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.8,,,percent of total billed charges,,
DAPSONE 25 MG TAB,2500009513,CDM,637,RC,7095413510,NDC,,,,,,outpatient,facility,25,UN,8.15,8.15,0.65,548.68,,5.78,,,percent of total billed charges,,,1.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.15,,,percent of total billed charges,,,5.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.98,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.15,,,fee schedule,,,8.15,,,percent of total billed charges,,,,,,,,,8.15,,,percent of total billed charges,,,5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,4.4,,,percent of total billed charges,,,4.24,,,percent of total billed charges,,,4.48,,,percent of total billed charges,,,,,,,,,4.81,,,percent of total billed charges,,,548.68,,,per diem,,,8.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.15,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.33,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.5,,,percent of total billed charges,,,6.59,,,percent of total billed charges,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,,,,,,,3.02,,,percent of total billed charges,,,3.02,,,percent of total billed charges,,,,,,,,,8.15,,,percent of total billed charges,,,8.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.65,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,7.58,,,percent of total billed charges,,,,,,,,,,,,,,,7.58,,,percent of total billed charges,,,7.58,,,percent of total billed charges,,,7.58,,,percent of total billed charges,,,6.11,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,8.15,,,percent of total billed charges,,,,,,,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.08,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.8,,,percent of total billed charges,,
DAPSONE 25 MG TAB,2500009513,CDM,637,RC,7095413510,NDC,999,EAPG,,,,outpatient,facility,25,UN,8.15,8.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DERMABOND,2500009560,CDM,637,RC,,,,,,,,inpatient,facility,1,UN,87.71,87.71,7.02,87.71,,,,,,,,,,,,,,87.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.71,,,percent of total billed charges,,,,,,,,,87.71,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,87.71,,,percent of total billed charges,,,74.55,,,percent of total billed charges,,,,,,,,,,,,,,,87.71,,,percent of total billed charges,,,46.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,87.71,,,percent of total billed charges,,,,,,,,,,,,,,,7.02,,,percent of total billed charges,,,87.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,87.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.68,,,percent of total billed charges,,
DERMABOND,2500009560,CDM,637,RC,,,,,,,,outpatient,facility,1,UN,87.71,87.71,7.02,548.68,,62.2,,,percent of total billed charges,,,21.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,87.71,,,percent of total billed charges,,,54.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,61.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,61.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,87.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,32.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,87.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,87.71,,,fee schedule,,,87.71,,,percent of total billed charges,,,,,,,,,87.71,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.49,,,percent of total billed charges,,,,,,,,,,,,,,,47.36,,,percent of total billed charges,,,45.61,,,percent of total billed charges,,,48.24,,,percent of total billed charges,,,,,,,,,51.75,,,percent of total billed charges,,,548.68,,,per diem,,,87.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,87.71,,,percent of total billed charges,,,74.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.58,,,percent of total billed charges,,,87.71,,,percent of total billed charges,,,87.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.17,,,percent of total billed charges,,,70.97,,,percent of total billed charges,,,,,,,,,,,,,,,35.08,,,percent of total billed charges,,,,,,,,,32.45,,,percent of total billed charges,,,32.45,,,percent of total billed charges,,,,,,,,,87.71,,,percent of total billed charges,,,87.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,87.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.02,,,percent of total billed charges,,,87.71,,,percent of total billed charges,,,,,,,,,,,,,,,87.71,,,percent of total billed charges,,,87.71,,,percent of total billed charges,,,,,,,,,81.59,,,percent of total billed charges,,,,,,,,,,,,,,,81.59,,,percent of total billed charges,,,81.59,,,percent of total billed charges,,,81.59,,,percent of total billed charges,,,65.78,,,percent of total billed charges,,,87.71,,,percent of total billed charges,,,87.71,,,percent of total billed charges,,,87.71,,,percent of total billed charges,,,,,,,,,61.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,51.68,,,percent of total billed charges,,
DERMABOND,2500009560,CDM,637,RC,999,EAPG,,,,,,outpatient,facility,1,UN,87.71,87.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DESIPRAMINE HCL 10 MG TAB,2500009580,CDM,637,RC,2315557801,NDC,,,,,,inpatient,facility,10,UN,5.02,5.02,0.4,5.02,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,,,,,,,5.02,,,percent of total billed charges,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,4.27,,,percent of total billed charges,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.96,,,percent of total billed charges,,
DESIPRAMINE HCL 10 MG TAB,2500009580,CDM,637,RC,2315557801,NDC,,,,,,outpatient,facility,10,UN,5.02,5.02,0.4,548.68,,3.56,,,percent of total billed charges,,,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.02,,,percent of total billed charges,,,3.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.84,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.02,,,fee schedule,,,5.02,,,percent of total billed charges,,,,,,,,,5.02,,,percent of total billed charges,,,3.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,,,,,,,2.96,,,percent of total billed charges,,,548.68,,,per diem,,,5.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.02,,,percent of total billed charges,,,4.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,5.02,,,percent of total billed charges,,,5.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.4,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,,,,,,,4.67,,,percent of total billed charges,,,,,,,,,,,,,,,4.67,,,percent of total billed charges,,,4.67,,,percent of total billed charges,,,4.67,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,,,,,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.96,,,percent of total billed charges,,
DESIPRAMINE HCL 10 MG TAB,2500009580,CDM,637,RC,2315557801,NDC,999,EAPG,,,,outpatient,facility,10,UN,5.02,5.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DESIPRAMINE HCL 25 MG TAB,2500009582,CDM,637,RC,2315557901,NDC,,,,,,inpatient,facility,25,UN,6.01,6.01,0.48,6.01,,,,,,,,,,,,,,6.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.01,,,percent of total billed charges,,,,,,,,,6.01,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.61,,,percent of total billed charges,,,,,,,,,,,,,,,6.01,,,percent of total billed charges,,,5.11,,,percent of total billed charges,,,,,,,,,,,,,,,6.01,,,percent of total billed charges,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,6.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.54,,,percent of total billed charges,,
DESIPRAMINE HCL 25 MG TAB,2500009582,CDM,637,RC,2315557901,NDC,,,,,,outpatient,facility,25,UN,6.01,6.01,0.48,548.68,,4.26,,,percent of total billed charges,,,1.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.01,,,percent of total billed charges,,,3.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.2,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.01,,,fee schedule,,,6.01,,,percent of total billed charges,,,,,,,,,6.01,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,,,,,,,,,,,,,3.25,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,,,,,,,3.55,,,percent of total billed charges,,,548.68,,,per diem,,,6.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.01,,,percent of total billed charges,,,5.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.19,,,percent of total billed charges,,,6.01,,,percent of total billed charges,,,6.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.05,,,percent of total billed charges,,,4.86,,,percent of total billed charges,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,,,,,,,2.22,,,percent of total billed charges,,,2.22,,,percent of total billed charges,,,,,,,,,6.01,,,percent of total billed charges,,,6.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.48,,,percent of total billed charges,,,6.01,,,percent of total billed charges,,,,,,,,,,,,,,,6.01,,,percent of total billed charges,,,6.01,,,percent of total billed charges,,,,,,,,,5.59,,,percent of total billed charges,,,,,,,,,,,,,,,5.59,,,percent of total billed charges,,,5.59,,,percent of total billed charges,,,5.59,,,percent of total billed charges,,,4.51,,,percent of total billed charges,,,6.01,,,percent of total billed charges,,,6.01,,,percent of total billed charges,,,6.01,,,percent of total billed charges,,,,,,,,,4.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.54,,,percent of total billed charges,,
DESIPRAMINE HCL 25 MG TAB,2500009582,CDM,637,RC,2315557901,NDC,999,EAPG,,,,outpatient,facility,25,UN,6.01,6.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DESMOPRESSIN 0.01  NASAL 5 ML,2500009592,CDM,637,RC,4733578891,NDC,,,,,,inpatient,facility,5,UN,812.63,812.63,65.01,812.63,,,,,,,,,,,,,,812.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,812.63,,,percent of total billed charges,,,,,,,,,812.63,,,percent of total billed charges,,,414.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,692.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,487.58,,,percent of total billed charges,,,,,,,,,,,,,,,812.63,,,percent of total billed charges,,,690.74,,,percent of total billed charges,,,,,,,,,,,,,,,812.63,,,percent of total billed charges,,,431.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,812.63,,,percent of total billed charges,,,,,,,,,,,,,,,65.01,,,percent of total billed charges,,,812.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,812.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,478.8,,,percent of total billed charges,,
DESMOPRESSIN 0.01  NASAL 5 ML,2500009592,CDM,637,RC,4733578891,NDC,,,,,,outpatient,facility,5,UN,812.63,812.63,65.01,812.63,,576.24,,,percent of total billed charges,,,198.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,812.63,,,percent of total billed charges,,,509.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,571.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,571.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,812.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,297.42,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,812.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,812.63,,,fee schedule,,,812.63,,,percent of total billed charges,,,,,,,,,812.63,,,percent of total billed charges,,,498.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,579,,,percent of total billed charges,,,,,,,,,,,,,,,438.82,,,percent of total billed charges,,,422.57,,,percent of total billed charges,,,446.95,,,percent of total billed charges,,,,,,,,,479.45,,,percent of total billed charges,,,548.68,,,per diem,,,812.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,812.63,,,percent of total billed charges,,,690.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,431.59,,,percent of total billed charges,,,812.63,,,percent of total billed charges,,,812.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,548.2,,,percent of total billed charges,,,657.58,,,percent of total billed charges,,,,,,,,,,,,,,,325.05,,,percent of total billed charges,,,,,,,,,300.67,,,percent of total billed charges,,,300.67,,,percent of total billed charges,,,,,,,,,812.63,,,percent of total billed charges,,,812.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,812.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,65.01,,,percent of total billed charges,,,812.63,,,percent of total billed charges,,,,,,,,,,,,,,,812.63,,,percent of total billed charges,,,812.63,,,percent of total billed charges,,,,,,,,,755.91,,,percent of total billed charges,,,,,,,,,,,,,,,755.91,,,percent of total billed charges,,,755.91,,,percent of total billed charges,,,755.91,,,percent of total billed charges,,,609.47,,,percent of total billed charges,,,812.63,,,percent of total billed charges,,,812.63,,,percent of total billed charges,,,812.63,,,percent of total billed charges,,,,,,,,,569.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,478.8,,,percent of total billed charges,,
DESMOPRESSIN 0.01  NASAL 5 ML,2500009592,CDM,637,RC,4733578891,NDC,999,EAPG,,,,outpatient,facility,5,UN,812.63,812.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DESMOPRESSIN ACET 0.1 MG TAB,2500009595,CDM,637,RC,2315548901,NDC,,,,,,inpatient,facility,0.1,UN,17.45,17.45,1.4,17.45,,,,,,,,,,,,,,17.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.45,,,percent of total billed charges,,,,,,,,,17.45,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.47,,,percent of total billed charges,,,,,,,,,,,,,,,17.45,,,percent of total billed charges,,,14.83,,,percent of total billed charges,,,,,,,,,,,,,,,17.45,,,percent of total billed charges,,,9.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,17.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,17.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.28,,,percent of total billed charges,,
DESMOPRESSIN ACET 0.1 MG TAB,2500009595,CDM,637,RC,2315548901,NDC,,,,,,outpatient,facility,0.1,UN,17.45,17.45,1.4,548.68,,12.37,,,percent of total billed charges,,,4.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,17.45,,,percent of total billed charges,,,10.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,12.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,12.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,17.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.39,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,17.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,17.45,,,fee schedule,,,17.45,,,percent of total billed charges,,,,,,,,,17.45,,,percent of total billed charges,,,10.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,9.42,,,percent of total billed charges,,,9.07,,,percent of total billed charges,,,9.6,,,percent of total billed charges,,,,,,,,,10.3,,,percent of total billed charges,,,548.68,,,per diem,,,17.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,17.45,,,percent of total billed charges,,,14.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.27,,,percent of total billed charges,,,17.45,,,percent of total billed charges,,,17.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.77,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,6.98,,,percent of total billed charges,,,,,,,,,6.46,,,percent of total billed charges,,,6.46,,,percent of total billed charges,,,,,,,,,17.45,,,percent of total billed charges,,,17.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.4,,,percent of total billed charges,,,17.45,,,percent of total billed charges,,,,,,,,,,,,,,,17.45,,,percent of total billed charges,,,17.45,,,percent of total billed charges,,,,,,,,,16.23,,,percent of total billed charges,,,,,,,,,,,,,,,16.23,,,percent of total billed charges,,,16.23,,,percent of total billed charges,,,16.23,,,percent of total billed charges,,,13.09,,,percent of total billed charges,,,17.45,,,percent of total billed charges,,,17.45,,,percent of total billed charges,,,17.45,,,percent of total billed charges,,,,,,,,,12.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.28,,,percent of total billed charges,,
DESMOPRESSIN ACET 0.1 MG TAB,2500009595,CDM,637,RC,2315548901,NDC,999,EAPG,,,,outpatient,facility,0.1,UN,17.45,17.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXAMETHASONE 0.1  OPH 5 ML,2500009632,CDM,637,RC,2420872002,NDC,,,,,,inpatient,facility,5,UN,177.87,177.87,14.23,177.87,,,,,,,,,,,,,,177.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.87,,,percent of total billed charges,,,,,,,,,177.87,,,percent of total billed charges,,,90.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.72,,,percent of total billed charges,,,,,,,,,,,,,,,177.87,,,percent of total billed charges,,,151.19,,,percent of total billed charges,,,,,,,,,,,,,,,177.87,,,percent of total billed charges,,,94.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,177.87,,,percent of total billed charges,,,,,,,,,,,,,,,14.23,,,percent of total billed charges,,,177.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,177.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.8,,,percent of total billed charges,,
DEXAMETHASONE 0.1  OPH 5 ML,2500009632,CDM,637,RC,2420872002,NDC,,,,,,outpatient,facility,5,UN,177.87,177.87,14.23,548.68,,126.13,,,percent of total billed charges,,,43.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,177.87,,,percent of total billed charges,,,111.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,125.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,125.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,177.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,65.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,177.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,177.87,,,fee schedule,,,177.87,,,percent of total billed charges,,,,,,,,,177.87,,,percent of total billed charges,,,109.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.73,,,percent of total billed charges,,,,,,,,,,,,,,,96.05,,,percent of total billed charges,,,92.49,,,percent of total billed charges,,,97.83,,,percent of total billed charges,,,,,,,,,104.94,,,percent of total billed charges,,,548.68,,,per diem,,,177.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,177.87,,,percent of total billed charges,,,151.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.47,,,percent of total billed charges,,,177.87,,,percent of total billed charges,,,177.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.99,,,percent of total billed charges,,,143.93,,,percent of total billed charges,,,,,,,,,,,,,,,71.15,,,percent of total billed charges,,,,,,,,,65.81,,,percent of total billed charges,,,65.81,,,percent of total billed charges,,,,,,,,,177.87,,,percent of total billed charges,,,177.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,177.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.23,,,percent of total billed charges,,,177.87,,,percent of total billed charges,,,,,,,,,,,,,,,177.87,,,percent of total billed charges,,,177.87,,,percent of total billed charges,,,,,,,,,165.45,,,percent of total billed charges,,,,,,,,,,,,,,,165.45,,,percent of total billed charges,,,165.45,,,percent of total billed charges,,,165.45,,,percent of total billed charges,,,133.4,,,percent of total billed charges,,,177.87,,,percent of total billed charges,,,177.87,,,percent of total billed charges,,,177.87,,,percent of total billed charges,,,,,,,,,124.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,104.8,,,percent of total billed charges,,
DEXAMETHASONE 0.1  OPH 5 ML,2500009632,CDM,637,RC,2420872002,NDC,999,EAPG,,,,outpatient,facility,5,UN,177.87,177.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXAMETHASONE 0.5 MG TAB,2500009633,CDM,637,RC,J8540,HCPCS,54817925,NDC,,,,inpatient,facility,0.5,UN,0.69,0.69,0.06,0.69,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,
DEXAMETHASONE 0.5 MG TAB,2500009633,CDM,637,RC,J8540,HCPCS,54817925,NDC,,,,outpatient,facility,0.5,UN,0.69,0.69,0.06,548.68,,0.07,,,fee schedule,,,0.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.69,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.69,,,fee schedule,,,0.69,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,0.41,,,percent of total billed charges,,,548.68,,,per diem,,,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.69,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,0.69,,,percent of total billed charges,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.07,,,fee schedule,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.41,,,percent of total billed charges,,
DEXAMETHASONE 0.5 MG TAB,2500009633,CDM,637,RC,J8540,HCPCS,54817925,NDC,999,EAPG,,outpatient,facility,0.5,UN,0.69,0.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXAMETHASONE 1 MG TAB,2500009641,CDM,637,RC,J8540,HCPCS,54817425,NDC,,,,inpatient,facility,1,UN,1.22,1.22,0.1,1.22,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,
DEXAMETHASONE 1 MG TAB,2500009641,CDM,637,RC,J8540,HCPCS,54817425,NDC,,,,outpatient,facility,1,UN,1.22,1.22,0.07,548.68,,0.07,,,fee schedule,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.22,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.45,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.22,,,fee schedule,,,1.22,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,0.72,,,percent of total billed charges,,,548.68,,,per diem,,,1.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.22,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1.22,,,percent of total billed charges,,,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.07,,,fee schedule,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.72,,,percent of total billed charges,,
DEXAMETHASONE 1 MG TAB,2500009641,CDM,637,RC,J8540,HCPCS,54817425,NDC,999,EAPG,,outpatient,facility,1,UN,1.22,1.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXAMETHASONE 4 MG TAB,2500009645,CDM,637,RC,J8540,HCPCS,641614525,NDC,,,,inpatient,facility,1,UN,3.99,3.99,0.32,3.99,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,
DEXAMETHASONE 4 MG TAB,2500009645,CDM,637,RC,J8540,HCPCS,641614525,NDC,,,,outpatient,facility,1,UN,3.99,3.99,0.07,548.68,,0.07,,,fee schedule,,,0.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.99,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.99,,,fee schedule,,,3.99,,,percent of total billed charges,,,,,,,,,3.99,,,percent of total billed charges,,,2.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,2.35,,,percent of total billed charges,,,548.68,,,per diem,,,3.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.99,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.69,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3.99,,,percent of total billed charges,,,3.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.32,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.07,,,fee schedule,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,3.99,,,percent of total billed charges,,,,,,,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.35,,,percent of total billed charges,,
DEXAMETHASONE 4 MG TAB,2500009645,CDM,637,RC,J8540,HCPCS,641614525,NDC,999,EAPG,,outpatient,facility,1,UN,3.99,3.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXMEDETOMIDINE 200MCG/50ML,2500009668,CDM,250,RC,7012113888,NDC,,,,,,inpatient,facility,50,UN,177.21,177.21,14.18,177.21,,,,,,,,,,,,,,177.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.21,,,percent of total billed charges,,,,,,,,,177.21,,,percent of total billed charges,,,90.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.33,,,percent of total billed charges,,,,,,,,,,,,,,,177.21,,,percent of total billed charges,,,150.63,,,percent of total billed charges,,,,,,,,,,,,,,,177.21,,,percent of total billed charges,,,94.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,177.21,,,percent of total billed charges,,,,,,,,,,,,,,,14.18,,,percent of total billed charges,,,177.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,177.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.41,,,percent of total billed charges,,
DEXMEDETOMIDINE 200MCG/50ML,2500009668,CDM,250,RC,7012113888,NDC,,,,,,outpatient,facility,50,UN,177.21,177.21,14.18,548.68,,125.66,,,percent of total billed charges,,,43.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,177.21,,,percent of total billed charges,,,111.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,124.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,124.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,177.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,64.86,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,177.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,177.21,,,fee schedule,,,177.21,,,percent of total billed charges,,,,,,,,,177.21,,,percent of total billed charges,,,108.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,104.55,,,percent of total billed charges,,,548.68,,,per diem,,,177.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,177.21,,,percent of total billed charges,,,150.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.12,,,percent of total billed charges,,,177.21,,,percent of total billed charges,,,177.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.55,,,percent of total billed charges,,,143.4,,,percent of total billed charges,,,,,,,,,,,,,,,70.88,,,percent of total billed charges,,,,,,,,,70.88,,,percent of total billed charges,,,70.88,,,percent of total billed charges,,,,,,,,,177.21,,,percent of total billed charges,,,177.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,177.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.18,,,percent of total billed charges,,,177.21,,,percent of total billed charges,,,,,,,,,,,,,,,177.21,,,percent of total billed charges,,,177.21,,,percent of total billed charges,,,,,,,,,70.88,,,percent of total billed charges,,,,,,,,,,,,,,,70.88,,,percent of total billed charges,,,70.88,,,percent of total billed charges,,,70.88,,,percent of total billed charges,,,132.91,,,percent of total billed charges,,,177.21,,,percent of total billed charges,,,177.21,,,percent of total billed charges,,,177.21,,,percent of total billed charges,,,,,,,,,124.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,104.41,,,percent of total billed charges,,
DEXMEDETOMIDINE 200MCG/50ML,2500009668,CDM,250,RC,7012113888,NDC,999,EAPG,,,,outpatient,facility,50,UN,177.21,177.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXMEDETOMIDINE 400MCG/100ML,2500009669,CDM,250,RC,7012113897,NDC,,,,,,inpatient,facility,100,UN,324.72,324.72,25.98,324.72,,,,,,,,,,,,,,324.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,324.72,,,percent of total billed charges,,,,,,,,,324.72,,,percent of total billed charges,,,165.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.83,,,percent of total billed charges,,,,,,,,,,,,,,,324.72,,,percent of total billed charges,,,276.01,,,percent of total billed charges,,,,,,,,,,,,,,,324.72,,,percent of total billed charges,,,172.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,324.72,,,percent of total billed charges,,,,,,,,,,,,,,,25.98,,,percent of total billed charges,,,324.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,324.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.33,,,percent of total billed charges,,
DEXMEDETOMIDINE 400MCG/100ML,2500009669,CDM,250,RC,7012113897,NDC,,,,,,outpatient,facility,100,UN,324.72,324.72,25.98,548.68,,230.26,,,percent of total billed charges,,,79.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,324.72,,,percent of total billed charges,,,203.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,228.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,228.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,324.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,118.85,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,324.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,324.72,,,fee schedule,,,324.72,,,percent of total billed charges,,,,,,,,,324.72,,,percent of total billed charges,,,199.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,191.58,,,percent of total billed charges,,,548.68,,,per diem,,,324.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,324.72,,,percent of total billed charges,,,276.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,172.46,,,percent of total billed charges,,,324.72,,,percent of total billed charges,,,324.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.06,,,percent of total billed charges,,,262.76,,,percent of total billed charges,,,,,,,,,,,,,,,129.89,,,percent of total billed charges,,,,,,,,,129.89,,,percent of total billed charges,,,129.89,,,percent of total billed charges,,,,,,,,,324.72,,,percent of total billed charges,,,324.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,324.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.98,,,percent of total billed charges,,,324.72,,,percent of total billed charges,,,,,,,,,,,,,,,324.72,,,percent of total billed charges,,,324.72,,,percent of total billed charges,,,,,,,,,129.89,,,percent of total billed charges,,,,,,,,,,,,,,,129.89,,,percent of total billed charges,,,129.89,,,percent of total billed charges,,,129.89,,,percent of total billed charges,,,243.54,,,percent of total billed charges,,,324.72,,,percent of total billed charges,,,324.72,,,percent of total billed charges,,,324.72,,,percent of total billed charges,,,,,,,,,227.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,191.33,,,percent of total billed charges,,
DEXMEDETOMIDINE 400MCG/100ML,2500009669,CDM,250,RC,7012113897,NDC,999,EAPG,,,,outpatient,facility,100,UN,324.72,324.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 10  1000 ML,2500009722,CDM,258,RC,338002304,NDC,,,,,,inpatient,facility,1000,UN,24.92,24.92,1.99,24.92,,,,,,,,,,,,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.92,,,percent of total billed charges,,,,,,,,,24.92,,,percent of total billed charges,,,12.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,24.92,,,percent of total billed charges,,,21.18,,,percent of total billed charges,,,,,,,,,,,,,,,24.92,,,percent of total billed charges,,,13.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.68,,,percent of total billed charges,,
DEXTROSE 10  1000 ML,2500009722,CDM,258,RC,338002304,NDC,,,,,,outpatient,facility,1000,UN,24.92,24.92,1.99,548.68,,17.67,,,percent of total billed charges,,,6.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,24.92,,,percent of total billed charges,,,15.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,17.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,17.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.12,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,24.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,24.92,,,fee schedule,,,24.92,,,percent of total billed charges,,,,,,,,,24.92,,,percent of total billed charges,,,15.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,14.7,,,percent of total billed charges,,,548.68,,,per diem,,,24.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,24.92,,,percent of total billed charges,,,21.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.24,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.81,,,percent of total billed charges,,,20.17,,,percent of total billed charges,,,,,,,,,,,,,,,9.97,,,percent of total billed charges,,,,,,,,,9.97,,,percent of total billed charges,,,9.97,,,percent of total billed charges,,,,,,,,,24.92,,,percent of total billed charges,,,24.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.99,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,24.92,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,,,,,,,9.97,,,percent of total billed charges,,,,,,,,,,,,,,,9.97,,,percent of total billed charges,,,9.97,,,percent of total billed charges,,,9.97,,,percent of total billed charges,,,18.69,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,,,,,,,17.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.68,,,percent of total billed charges,,
DEXTROSE 10  1000 ML,2500009722,CDM,258,RC,338002304,NDC,999,EAPG,,,,outpatient,facility,1000,UN,24.92,24.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 10  250 ML,2500009723,CDM,258,RC,264752020,NDC,,,,,,inpatient,facility,250,UN,13.27,13.27,1.06,13.27,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,13.27,,,percent of total billed charges,,,6.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.96,,,percent of total billed charges,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,11.28,,,percent of total billed charges,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,7.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.82,,,percent of total billed charges,,
DEXTROSE 10  250 ML,2500009723,CDM,258,RC,264752020,NDC,,,,,,outpatient,facility,250,UN,13.27,13.27,1.06,548.68,,9.41,,,percent of total billed charges,,,3.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.27,,,percent of total billed charges,,,8.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.86,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.27,,,fee schedule,,,13.27,,,percent of total billed charges,,,,,,,,,13.27,,,percent of total billed charges,,,8.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.83,,,percent of total billed charges,,,548.68,,,per diem,,,13.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.27,,,percent of total billed charges,,,11.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.05,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.95,,,percent of total billed charges,,,10.74,,,percent of total billed charges,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,,,,,,,5.31,,,percent of total billed charges,,,5.31,,,percent of total billed charges,,,,,,,,,13.27,,,percent of total billed charges,,,13.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.06,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,5.31,,,percent of total billed charges,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,5.31,,,percent of total billed charges,,,5.31,,,percent of total billed charges,,,9.95,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,9.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.82,,,percent of total billed charges,,
DEXTROSE 10  250 ML,2500009723,CDM,258,RC,264752020,NDC,999,EAPG,,,,outpatient,facility,250,UN,13.27,13.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 10  500 ML,2500009724,CDM,258,RC,990793002,NDC,,,,,,inpatient,facility,500,UN,36.37,36.37,2.91,36.37,,,,,,,,,,,,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.37,,,percent of total billed charges,,,,,,,,,36.37,,,percent of total billed charges,,,18.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.82,,,percent of total billed charges,,,,,,,,,,,,,,,36.37,,,percent of total billed charges,,,30.91,,,percent of total billed charges,,,,,,,,,,,,,,,36.37,,,percent of total billed charges,,,19.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.43,,,percent of total billed charges,,
DEXTROSE 10  500 ML,2500009724,CDM,258,RC,990793002,NDC,,,,,,outpatient,facility,500,UN,36.37,36.37,2.91,548.68,,25.79,,,percent of total billed charges,,,8.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,36.37,,,percent of total billed charges,,,22.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,25.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,25.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,13.31,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,36.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,36.37,,,fee schedule,,,36.37,,,percent of total billed charges,,,,,,,,,36.37,,,percent of total billed charges,,,22.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,21.46,,,percent of total billed charges,,,548.68,,,per diem,,,36.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,36.37,,,percent of total billed charges,,,30.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.32,,,percent of total billed charges,,,36.37,,,percent of total billed charges,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.54,,,percent of total billed charges,,,29.43,,,percent of total billed charges,,,,,,,,,,,,,,,14.55,,,percent of total billed charges,,,,,,,,,14.55,,,percent of total billed charges,,,14.55,,,percent of total billed charges,,,,,,,,,36.37,,,percent of total billed charges,,,36.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,36.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.91,,,percent of total billed charges,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,36.37,,,percent of total billed charges,,,36.37,,,percent of total billed charges,,,,,,,,,14.55,,,percent of total billed charges,,,,,,,,,,,,,,,14.55,,,percent of total billed charges,,,14.55,,,percent of total billed charges,,,14.55,,,percent of total billed charges,,,27.28,,,percent of total billed charges,,,36.37,,,percent of total billed charges,,,36.37,,,percent of total billed charges,,,36.37,,,percent of total billed charges,,,,,,,,,25.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,21.43,,,percent of total billed charges,,
DEXTROSE 10  500 ML,2500009724,CDM,258,RC,990793002,NDC,999,EAPG,,,,outpatient,facility,500,UN,36.37,36.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 25  10 ML SYR,2500009734,CDM,250,RC,409177510,NDC,,,,,,inpatient,facility,10,UN,51.05,51.05,4.08,51.05,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,,,,,,,51.05,,,percent of total billed charges,,,26.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.63,,,percent of total billed charges,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,43.39,,,percent of total billed charges,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,27.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,4.08,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.08,,,percent of total billed charges,,
DEXTROSE 25  10 ML SYR,2500009734,CDM,250,RC,409177510,NDC,,,,,,outpatient,facility,10,UN,51.05,51.05,4.08,548.68,,36.2,,,percent of total billed charges,,,12.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,51.05,,,percent of total billed charges,,,31.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,35.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,35.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,18.68,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,51.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,51.05,,,fee schedule,,,51.05,,,percent of total billed charges,,,,,,,,,51.05,,,percent of total billed charges,,,31.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,30.12,,,percent of total billed charges,,,548.68,,,per diem,,,51.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,51.05,,,percent of total billed charges,,,43.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.11,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.44,,,percent of total billed charges,,,41.31,,,percent of total billed charges,,,,,,,,,,,,,,,20.42,,,percent of total billed charges,,,,,,,,,20.42,,,percent of total billed charges,,,20.42,,,percent of total billed charges,,,,,,,,,51.05,,,percent of total billed charges,,,51.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,51.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.08,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,,,,,,,20.42,,,percent of total billed charges,,,,,,,,,,,,,,,20.42,,,percent of total billed charges,,,20.42,,,percent of total billed charges,,,20.42,,,percent of total billed charges,,,38.29,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,,,,,,,35.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,30.08,,,percent of total billed charges,,
DEXTROSE 25  10 ML SYR,2500009734,CDM,250,RC,409177510,NDC,999,EAPG,,,,outpatient,facility,10,UN,51.05,51.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 5 /0.225  NS 500 ML,2500009752,CDM,258,RC,338007703,NDC,,,,,,inpatient,facility,500,UN,16.93,16.93,1.35,16.93,,,,,,,,,,,,,,16.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.93,,,percent of total billed charges,,,,,,,,,16.93,,,percent of total billed charges,,,8.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.16,,,percent of total billed charges,,,,,,,,,,,,,,,16.93,,,percent of total billed charges,,,14.39,,,percent of total billed charges,,,,,,,,,,,,,,,16.93,,,percent of total billed charges,,,8.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,16.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,16.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.98,,,percent of total billed charges,,
DEXTROSE 5 /0.225  NS 500 ML,2500009752,CDM,258,RC,338007703,NDC,,,,,,outpatient,facility,500,UN,16.93,16.93,1.35,548.68,,12.01,,,percent of total billed charges,,,4.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,16.93,,,percent of total billed charges,,,10.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,11.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,11.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.2,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,16.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,16.93,,,fee schedule,,,16.93,,,percent of total billed charges,,,,,,,,,16.93,,,percent of total billed charges,,,10.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,9.99,,,percent of total billed charges,,,548.68,,,per diem,,,16.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,16.93,,,percent of total billed charges,,,14.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.99,,,percent of total billed charges,,,16.93,,,percent of total billed charges,,,16.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.42,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,6.77,,,percent of total billed charges,,,,,,,,,6.77,,,percent of total billed charges,,,6.77,,,percent of total billed charges,,,,,,,,,16.93,,,percent of total billed charges,,,16.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.35,,,percent of total billed charges,,,16.93,,,percent of total billed charges,,,,,,,,,,,,,,,16.93,,,percent of total billed charges,,,16.93,,,percent of total billed charges,,,,,,,,,6.77,,,percent of total billed charges,,,,,,,,,,,,,,,6.77,,,percent of total billed charges,,,6.77,,,percent of total billed charges,,,6.77,,,percent of total billed charges,,,12.7,,,percent of total billed charges,,,16.93,,,percent of total billed charges,,,16.93,,,percent of total billed charges,,,16.93,,,percent of total billed charges,,,,,,,,,11.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.98,,,percent of total billed charges,,
DEXTROSE 5 /0.225  NS 500 ML,2500009752,CDM,258,RC,338007703,NDC,999,EAPG,,,,outpatient,facility,500,UN,16.93,16.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 5 /0.225  NS 1000ML,2500009753,CDM,258,RC,990792409,NDC,,,,,,inpatient,facility,1000,UN,18.18,18.18,1.45,18.18,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,,,,,,,18.18,,,percent of total billed charges,,,9.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.91,,,percent of total billed charges,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,15.45,,,percent of total billed charges,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,9.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.71,,,percent of total billed charges,,
DEXTROSE 5 /0.225  NS 1000ML,2500009753,CDM,258,RC,990792409,NDC,,,,,,outpatient,facility,1000,UN,18.18,18.18,1.45,548.68,,12.89,,,percent of total billed charges,,,4.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,18.18,,,percent of total billed charges,,,11.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,12.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,12.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,18.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,18.18,,,fee schedule,,,18.18,,,percent of total billed charges,,,,,,,,,18.18,,,percent of total billed charges,,,11.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,10.73,,,percent of total billed charges,,,548.68,,,per diem,,,18.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,18.18,,,percent of total billed charges,,,15.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.66,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.26,,,percent of total billed charges,,,14.71,,,percent of total billed charges,,,,,,,,,,,,,,,7.27,,,percent of total billed charges,,,,,,,,,7.27,,,percent of total billed charges,,,7.27,,,percent of total billed charges,,,,,,,,,18.18,,,percent of total billed charges,,,18.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.45,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,,,,,,,7.27,,,percent of total billed charges,,,,,,,,,,,,,,,7.27,,,percent of total billed charges,,,7.27,,,percent of total billed charges,,,7.27,,,percent of total billed charges,,,13.63,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,18.18,,,percent of total billed charges,,,,,,,,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.71,,,percent of total billed charges,,
DEXTROSE 5 /0.225  NS 1000ML,2500009753,CDM,258,RC,990792409,NDC,999,EAPG,,,,outpatient,facility,1000,UN,18.18,18.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 5 /0.45  NS 1000 ML,2500009756,CDM,636,RC,S5010,HCPCS,264761200,NDC,,,,inpatient,facility,1000,UN,10.1,10.1,0.81,10.1,,,,,,,,,,,,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.1,,,percent of total billed charges,,,,,,,,,10.1,,,percent of total billed charges,,,5.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.06,,,percent of total billed charges,,,,,,,,,,,,,,,10.1,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,10.1,,,percent of total billed charges,,,5.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.95,,,percent of total billed charges,,
DEXTROSE 5 /0.45  NS 1000 ML,2500009756,CDM,636,RC,S5010,HCPCS,264761200,NDC,,,,outpatient,facility,1000,UN,10.1,10.1,0.81,548.68,,7.16,,,percent of total billed charges,,,2.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.1,,,percent of total billed charges,,,11.69,,,fee schedule,,,11.06,,,fee schedule,,,,,,,,,11.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.7,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.1,,,fee schedule,,,10.1,,,percent of total billed charges,,,,,,,,,10.1,,,percent of total billed charges,,,6.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,5.96,,,percent of total billed charges,,,548.68,,,per diem,,,10.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.1,,,percent of total billed charges,,,8.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.36,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.81,,,percent of total billed charges,,,8.17,,,percent of total billed charges,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,,,,,,,10.1,,,fee schedule,,,9.72,,,fee schedule,,,,,,,,,10.1,,,percent of total billed charges,,,10.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.81,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,10.1,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,,,,,,,5.78,,,fee schedule,,,,,,,,,,,,,,,5,,,fee schedule,,,6.67,,,fee schedule,,,3.76,,,fee schedule,,,7.57,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,,,,,,,7.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.95,,,percent of total billed charges,,
DEXTROSE 5 /0.45  NS 1000 ML,2500009756,CDM,636,RC,S5010,HCPCS,264761200,NDC,999,EAPG,,outpatient,facility,1000,UN,10.1,10.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 5 /0.45  NS 500 ML,2500009757,CDM,258,RC,264761210,NDC,,,,,,inpatient,facility,500,UN,12.9,12.9,1.03,12.9,,,,,,,,,,,,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.9,,,percent of total billed charges,,,,,,,,,12.9,,,percent of total billed charges,,,6.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.74,,,percent of total billed charges,,,,,,,,,,,,,,,12.9,,,percent of total billed charges,,,10.96,,,percent of total billed charges,,,,,,,,,,,,,,,12.9,,,percent of total billed charges,,,6.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.6,,,percent of total billed charges,,
DEXTROSE 5 /0.45  NS 500 ML,2500009757,CDM,258,RC,264761210,NDC,,,,,,outpatient,facility,500,UN,12.9,12.9,1.03,548.68,,9.15,,,percent of total billed charges,,,3.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,12.9,,,percent of total billed charges,,,8.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.72,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,12.9,,,fee schedule,,,12.9,,,percent of total billed charges,,,,,,,,,12.9,,,percent of total billed charges,,,7.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.61,,,percent of total billed charges,,,548.68,,,per diem,,,12.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12.9,,,percent of total billed charges,,,10.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.85,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.7,,,percent of total billed charges,,,10.44,,,percent of total billed charges,,,,,,,,,,,,,,,5.16,,,percent of total billed charges,,,,,,,,,5.16,,,percent of total billed charges,,,5.16,,,percent of total billed charges,,,,,,,,,12.9,,,percent of total billed charges,,,12.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.03,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,12.9,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,,,,,,,5.16,,,percent of total billed charges,,,,,,,,,,,,,,,5.16,,,percent of total billed charges,,,5.16,,,percent of total billed charges,,,5.16,,,percent of total billed charges,,,9.68,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,,,,,,,9.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.6,,,percent of total billed charges,,
DEXTROSE 5 /0.45  NS 500 ML,2500009757,CDM,258,RC,264761210,NDC,999,EAPG,,,,outpatient,facility,500,UN,12.9,12.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 50  50 ML INJ,2500009760,CDM,250,RC,J3490,HCPCS,409751716,NDC,,,,inpatient,facility,50,UN,53.79,53.79,4.3,53.79,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,,,,,,,53.79,,,percent of total billed charges,,,27.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.27,,,percent of total billed charges,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,45.72,,,percent of total billed charges,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,28.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.69,,,percent of total billed charges,,
DEXTROSE 50  50 ML INJ,2500009760,CDM,250,RC,J3490,HCPCS,409751716,NDC,,,,outpatient,facility,50,UN,53.79,53.79,1.2,548.68,,38.14,,,percent of total billed charges,,,13.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,53.79,,,percent of total billed charges,,,33.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,37.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,37.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,19.69,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,53.79,,,fee schedule,,,53.79,,,percent of total billed charges,,,,,,,,,53.79,,,percent of total billed charges,,,32.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.33,,,percent of total billed charges,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,,,,,,,31.74,,,percent of total billed charges,,,548.68,,,per diem,,,53.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,53.79,,,percent of total billed charges,,,45.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.57,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.29,,,percent of total billed charges,,,43.53,,,percent of total billed charges,,,,,,,,,,,,,,,21.52,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,53.79,,,percent of total billed charges,,,53.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,53.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.3,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,,53.79,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,40.34,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,53.79,,,percent of total billed charges,,,,,,,,,37.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,31.69,,,percent of total billed charges,,
DEXTROSE 50  50 ML INJ,2500009760,CDM,250,RC,J3490,HCPCS,409751716,NDC,435,EAPG,,outpatient,facility,50,UN,53.79,53.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXTROSE 50  50 ML INJ,2500009761,CDM,250,RC,409664802,NDC,,,,,,inpatient,facility,50,UN,14.22,14.22,1.14,14.22,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,,,,,,,14.22,,,percent of total billed charges,,,7.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.53,,,percent of total billed charges,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,12.09,,,percent of total billed charges,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,7.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.38,,,percent of total billed charges,,
DEXTROSE 50  50 ML INJ,2500009761,CDM,250,RC,409664802,NDC,,,,,,outpatient,facility,50,UN,14.22,14.22,1.14,548.68,,10.08,,,percent of total billed charges,,,3.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.22,,,percent of total billed charges,,,8.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.2,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.22,,,fee schedule,,,14.22,,,percent of total billed charges,,,,,,,,,14.22,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,8.39,,,percent of total billed charges,,,548.68,,,per diem,,,14.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.22,,,percent of total billed charges,,,12.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.55,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.59,,,percent of total billed charges,,,11.51,,,percent of total billed charges,,,,,,,,,,,,,,,5.69,,,percent of total billed charges,,,,,,,,,5.69,,,percent of total billed charges,,,5.69,,,percent of total billed charges,,,,,,,,,14.22,,,percent of total billed charges,,,14.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.14,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,,,,,,,5.69,,,percent of total billed charges,,,,,,,,,,,,,,,5.69,,,percent of total billed charges,,,5.69,,,percent of total billed charges,,,5.69,,,percent of total billed charges,,,10.67,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,,,,,,,9.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.11,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.38,,,percent of total billed charges,,
DEXTROSE 50  50 ML INJ,2500009761,CDM,250,RC,409664802,NDC,999,EAPG,,,,outpatient,facility,50,UN,14.22,14.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIAZEPAM 2 MG TAB,2500009822,CDM,637,RC,172392560,NDC,,,,,,inpatient,facility,2,UN,0.43,0.43,0.03,0.43,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,
DIAZEPAM 2 MG TAB,2500009822,CDM,637,RC,172392560,NDC,,,,,,outpatient,facility,2,UN,0.43,0.43,0.03,548.68,,0.3,,,percent of total billed charges,,,0.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.43,,,percent of total billed charges,,,0.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.16,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.43,,,fee schedule,,,0.43,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,0.25,,,percent of total billed charges,,,548.68,,,per diem,,,0.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.43,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,0.16,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.25,,,percent of total billed charges,,
DIAZEPAM 2 MG TAB,2500009822,CDM,637,RC,172392560,NDC,999,EAPG,,,,outpatient,facility,2,UN,0.43,0.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIAZEPAM 5 MG TAB,2500009823,CDM,637,RC,6809475062,NDC,,,,,,inpatient,facility,5,UN,1.05,1.05,0.08,1.05,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,1.05,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,
DIAZEPAM 5 MG TAB,2500009823,CDM,637,RC,6809475062,NDC,,,,,,outpatient,facility,5,UN,1.05,1.05,0.08,548.68,,0.74,,,percent of total billed charges,,,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.05,,,percent of total billed charges,,,0.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.38,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.05,,,fee schedule,,,1.05,,,percent of total billed charges,,,,,,,,,1.05,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,548.68,,,per diem,,,1.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.05,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,1.05,,,percent of total billed charges,,,1.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.62,,,percent of total billed charges,,
DIAZEPAM 5 MG TAB,2500009823,CDM,637,RC,6809475062,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.05,1.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIAZEPAM RECTAL 10 MG/KIT,2500009826,CDM,637,RC,6868265220,NDC,,,,,,inpatient,facility,10,UN,500.58,500.58,40.05,500.58,,,,,,,,,,,,,,500.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.58,,,percent of total billed charges,,,,,,,,,500.58,,,percent of total billed charges,,,255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,426.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,300.35,,,percent of total billed charges,,,,,,,,,,,,,,,500.58,,,percent of total billed charges,,,425.49,,,percent of total billed charges,,,,,,,,,,,,,,,500.58,,,percent of total billed charges,,,265.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,500.58,,,percent of total billed charges,,,,,,,,,,,,,,,40.05,,,percent of total billed charges,,,500.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,500.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,294.94,,,percent of total billed charges,,
DIAZEPAM RECTAL 10 MG/KIT,2500009826,CDM,637,RC,6868265220,NDC,,,,,,outpatient,facility,10,UN,500.58,500.58,40.05,548.68,,354.96,,,percent of total billed charges,,,122.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,500.58,,,percent of total billed charges,,,313.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,351.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,351.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,500.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,183.21,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,500.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,500.58,,,fee schedule,,,500.58,,,percent of total billed charges,,,,,,,,,500.58,,,percent of total billed charges,,,306.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,356.66,,,percent of total billed charges,,,,,,,,,,,,,,,270.31,,,percent of total billed charges,,,260.3,,,percent of total billed charges,,,275.32,,,percent of total billed charges,,,,,,,,,295.34,,,percent of total billed charges,,,548.68,,,per diem,,,500.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,500.58,,,percent of total billed charges,,,425.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,265.86,,,percent of total billed charges,,,500.58,,,percent of total billed charges,,,500.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.69,,,percent of total billed charges,,,405.07,,,percent of total billed charges,,,,,,,,,,,,,,,200.23,,,percent of total billed charges,,,,,,,,,185.21,,,percent of total billed charges,,,185.21,,,percent of total billed charges,,,,,,,,,500.58,,,percent of total billed charges,,,500.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,500.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.05,,,percent of total billed charges,,,500.58,,,percent of total billed charges,,,,,,,,,,,,,,,500.58,,,percent of total billed charges,,,500.58,,,percent of total billed charges,,,,,,,,,465.64,,,percent of total billed charges,,,,,,,,,,,,,,,465.64,,,percent of total billed charges,,,465.64,,,percent of total billed charges,,,465.64,,,percent of total billed charges,,,375.44,,,percent of total billed charges,,,500.58,,,percent of total billed charges,,,500.58,,,percent of total billed charges,,,500.58,,,percent of total billed charges,,,,,,,,,350.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,294.94,,,percent of total billed charges,,
DIAZEPAM RECTAL 10 MG/KIT,2500009826,CDM,637,RC,6868265220,NDC,999,EAPG,,,,outpatient,facility,10,UN,500.58,500.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DICLOFENAC SOD 0.1  OPH 2.5 ML,2500009860,CDM,637,RC,6131401425,NDC,,,,,,inpatient,facility,2.5,UN,147.74,147.74,11.82,147.74,,,,,,,,,,,,,,147.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.74,,,percent of total billed charges,,,,,,,,,147.74,,,percent of total billed charges,,,75.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.64,,,percent of total billed charges,,,,,,,,,,,,,,,147.74,,,percent of total billed charges,,,125.58,,,percent of total billed charges,,,,,,,,,,,,,,,147.74,,,percent of total billed charges,,,78.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,147.74,,,percent of total billed charges,,,,,,,,,,,,,,,11.82,,,percent of total billed charges,,,147.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,147.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.05,,,percent of total billed charges,,
DICLOFENAC SOD 0.1  OPH 2.5 ML,2500009860,CDM,637,RC,6131401425,NDC,,,,,,outpatient,facility,2.5,UN,147.74,147.74,11.82,548.68,,104.76,,,percent of total billed charges,,,36.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,147.74,,,percent of total billed charges,,,92.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,103.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,103.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,147.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,54.07,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,147.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,147.74,,,fee schedule,,,147.74,,,percent of total billed charges,,,,,,,,,147.74,,,percent of total billed charges,,,90.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.26,,,percent of total billed charges,,,,,,,,,,,,,,,79.78,,,percent of total billed charges,,,76.82,,,percent of total billed charges,,,81.26,,,percent of total billed charges,,,,,,,,,87.17,,,percent of total billed charges,,,548.68,,,per diem,,,147.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,147.74,,,percent of total billed charges,,,125.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,78.46,,,percent of total billed charges,,,147.74,,,percent of total billed charges,,,147.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.67,,,percent of total billed charges,,,119.55,,,percent of total billed charges,,,,,,,,,,,,,,,59.1,,,percent of total billed charges,,,,,,,,,54.66,,,percent of total billed charges,,,54.66,,,percent of total billed charges,,,,,,,,,147.74,,,percent of total billed charges,,,147.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,147.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.82,,,percent of total billed charges,,,147.74,,,percent of total billed charges,,,,,,,,,,,,,,,147.74,,,percent of total billed charges,,,147.74,,,percent of total billed charges,,,,,,,,,137.43,,,percent of total billed charges,,,,,,,,,,,,,,,137.43,,,percent of total billed charges,,,137.43,,,percent of total billed charges,,,137.43,,,percent of total billed charges,,,110.81,,,percent of total billed charges,,,147.74,,,percent of total billed charges,,,147.74,,,percent of total billed charges,,,147.74,,,percent of total billed charges,,,,,,,,,103.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,87.05,,,percent of total billed charges,,
DICLOFENAC SOD 0.1  OPH 2.5 ML,2500009860,CDM,637,RC,6131401425,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,147.74,147.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DICLOFENAC 1  GEL 100 GM,2500009861,CDM,637,RC,6909752444,NDC,,,,,,inpatient,facility,100,UN,173.65,173.65,13.89,173.65,,,,,,,,,,,,,,173.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.65,,,percent of total billed charges,,,,,,,,,173.65,,,percent of total billed charges,,,88.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.19,,,percent of total billed charges,,,,,,,,,,,,,,,173.65,,,percent of total billed charges,,,147.6,,,percent of total billed charges,,,,,,,,,,,,,,,173.65,,,percent of total billed charges,,,92.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,173.65,,,percent of total billed charges,,,,,,,,,,,,,,,13.89,,,percent of total billed charges,,,173.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.31,,,percent of total billed charges,,
DICLOFENAC 1  GEL 100 GM,2500009861,CDM,637,RC,6909752444,NDC,,,,,,outpatient,facility,100,UN,173.65,173.65,13.89,548.68,,123.14,,,percent of total billed charges,,,42.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,173.65,,,percent of total billed charges,,,108.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,122.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,122.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,173.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,63.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,173.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,173.65,,,fee schedule,,,173.65,,,percent of total billed charges,,,,,,,,,173.65,,,percent of total billed charges,,,106.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.73,,,percent of total billed charges,,,,,,,,,,,,,,,93.77,,,percent of total billed charges,,,90.3,,,percent of total billed charges,,,95.51,,,percent of total billed charges,,,,,,,,,102.45,,,percent of total billed charges,,,548.68,,,per diem,,,173.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,173.65,,,percent of total billed charges,,,147.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,92.23,,,percent of total billed charges,,,173.65,,,percent of total billed charges,,,173.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.14,,,percent of total billed charges,,,140.52,,,percent of total billed charges,,,,,,,,,,,,,,,69.46,,,percent of total billed charges,,,,,,,,,64.25,,,percent of total billed charges,,,64.25,,,percent of total billed charges,,,,,,,,,173.65,,,percent of total billed charges,,,173.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,173.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.89,,,percent of total billed charges,,,173.65,,,percent of total billed charges,,,,,,,,,,,,,,,173.65,,,percent of total billed charges,,,173.65,,,percent of total billed charges,,,,,,,,,161.53,,,percent of total billed charges,,,,,,,,,,,,,,,161.53,,,percent of total billed charges,,,161.53,,,percent of total billed charges,,,161.53,,,percent of total billed charges,,,130.24,,,percent of total billed charges,,,173.65,,,percent of total billed charges,,,173.65,,,percent of total billed charges,,,173.65,,,percent of total billed charges,,,,,,,,,121.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,102.31,,,percent of total billed charges,,
DICLOFENAC 1  GEL 100 GM,2500009861,CDM,637,RC,6909752444,NDC,999,EAPG,,,,outpatient,facility,100,UN,173.65,173.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DICLOFENAC SOD 25 MG TABEC,2500009863,CDM,637,RC,1657120310,NDC,,,,,,inpatient,facility,25,UN,4.68,4.68,0.37,4.68,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,2.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,
DICLOFENAC SOD 25 MG TABEC,2500009863,CDM,637,RC,1657120310,NDC,,,,,,outpatient,facility,25,UN,4.68,4.68,0.37,548.68,,3.32,,,percent of total billed charges,,,1.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.68,,,percent of total billed charges,,,2.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.68,,,fee schedule,,,4.68,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,2.76,,,percent of total billed charges,,,548.68,,,per diem,,,4.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.68,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,1.73,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.37,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,4.35,,,percent of total billed charges,,,,,,,,,,,,,,,4.35,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.76,,,percent of total billed charges,,
DICLOFENAC SOD 25 MG TABEC,2500009863,CDM,637,RC,1657120310,NDC,999,EAPG,,,,outpatient,facility,25,UN,4.68,4.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DICYCLOMINE HCL 10 MG CAP,2500009880,CDM,637,RC,904698761,NDC,,,,,,inpatient,facility,10,UN,1.88,1.88,0.15,1.88,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,
DICYCLOMINE HCL 10 MG CAP,2500009880,CDM,637,RC,904698761,NDC,,,,,,outpatient,facility,10,UN,1.88,1.88,0.15,548.68,,1.33,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.88,,,percent of total billed charges,,,1.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.69,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.88,,,fee schedule,,,1.88,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,1.11,,,percent of total billed charges,,,548.68,,,per diem,,,1.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.88,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,0.7,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.11,,,percent of total billed charges,,
DICYCLOMINE HCL 10 MG CAP,2500009880,CDM,637,RC,904698761,NDC,999,EAPG,,,,outpatient,facility,10,UN,1.88,1.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DICYCLOMINE HCL 20 MG TAB,2500009882,CDM,637,RC,904698861,NDC,,,,,,inpatient,facility,20,UN,1.85,1.85,0.15,1.85,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,
DICYCLOMINE HCL 20 MG TAB,2500009882,CDM,637,RC,904698861,NDC,,,,,,outpatient,facility,20,UN,1.85,1.85,0.15,548.68,,1.31,,,percent of total billed charges,,,0.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.85,,,percent of total billed charges,,,1.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.68,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.85,,,fee schedule,,,1.85,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,548.68,,,per diem,,,1.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.85,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.09,,,percent of total billed charges,,
DICYCLOMINE HCL 20 MG TAB,2500009882,CDM,637,RC,904698861,NDC,999,EAPG,,,,outpatient,facility,20,UN,1.85,1.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIGOXIN 0.125 MG TAB,2500009940,CDM,637,RC,904592161,NDC,,,,,,inpatient,facility,0.125,UN,4.45,4.45,0.36,4.45,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,,,,,,,4.45,,,percent of total billed charges,,,2.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,3.78,,,percent of total billed charges,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,
DIGOXIN 0.125 MG TAB,2500009940,CDM,637,RC,904592161,NDC,,,,,,outpatient,facility,0.125,UN,4.45,4.45,0.36,548.68,,3.16,,,percent of total billed charges,,,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.45,,,percent of total billed charges,,,2.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.45,,,fee schedule,,,4.45,,,percent of total billed charges,,,,,,,,,4.45,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.45,,,percent of total billed charges,,,,,,,,,2.63,,,percent of total billed charges,,,548.68,,,per diem,,,4.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.45,,,percent of total billed charges,,,3.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,1.65,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,4.45,,,percent of total billed charges,,,4.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.36,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,4.14,,,percent of total billed charges,,,,,,,,,,,,,,,4.14,,,percent of total billed charges,,,4.14,,,percent of total billed charges,,,4.14,,,percent of total billed charges,,,3.34,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,3.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.62,,,percent of total billed charges,,
DIGOXIN 0.125 MG TAB,2500009940,CDM,637,RC,904592161,NDC,999,EAPG,,,,outpatient,facility,0.125,UN,4.45,4.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIGOXIN 0.25 MG TAB,2500009941,CDM,637,RC,904592261,NDC,,,,,,inpatient,facility,0.25,UN,4.46,4.46,0.36,4.46,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,4.46,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.63,,,percent of total billed charges,,
DIGOXIN 0.25 MG TAB,2500009941,CDM,637,RC,904592261,NDC,,,,,,outpatient,facility,0.25,UN,4.46,4.46,0.36,548.68,,3.16,,,percent of total billed charges,,,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.46,,,percent of total billed charges,,,2.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.46,,,fee schedule,,,4.46,,,percent of total billed charges,,,,,,,,,4.46,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,2.32,,,percent of total billed charges,,,2.45,,,percent of total billed charges,,,,,,,,,2.63,,,percent of total billed charges,,,548.68,,,per diem,,,4.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.46,,,percent of total billed charges,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,,3.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,1.65,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,4.46,,,percent of total billed charges,,,4.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.36,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,4.15,,,percent of total billed charges,,,,,,,,,,,,,,,4.15,,,percent of total billed charges,,,4.15,,,percent of total billed charges,,,4.15,,,percent of total billed charges,,,3.34,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.63,,,percent of total billed charges,,
DIGOXIN 0.25 MG TAB,2500009941,CDM,637,RC,904592261,NDC,999,EAPG,,,,outpatient,facility,0.25,UN,4.46,4.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM CD 120 MG CAPCR,2500009970,CDM,637,RC,6050500146,NDC,,,,,,inpatient,facility,120,UN,3.76,3.76,0.3,3.76,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,
DILTIAZEM CD 120 MG CAPCR,2500009970,CDM,637,RC,6050500146,NDC,,,,,,outpatient,facility,120,UN,3.76,3.76,0.3,548.68,,2.67,,,percent of total billed charges,,,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.76,,,percent of total billed charges,,,2.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.38,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.76,,,fee schedule,,,3.76,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,,,,,,,2.22,,,percent of total billed charges,,,548.68,,,per diem,,,3.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.76,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,1.39,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,2.82,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.22,,,percent of total billed charges,,
DILTIAZEM CD 120 MG CAPCR,2500009970,CDM,637,RC,6050500146,NDC,999,EAPG,,,,outpatient,facility,120,UN,3.76,3.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM CD 180 MG CAPCR,2500009972,CDM,637,RC,6050500156,NDC,,,,,,inpatient,facility,180,UN,4.42,4.42,0.35,4.42,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,
DILTIAZEM CD 180 MG CAPCR,2500009972,CDM,637,RC,6050500156,NDC,,,,,,outpatient,facility,180,UN,4.42,4.42,0.35,548.68,,3.13,,,percent of total billed charges,,,1.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.42,,,percent of total billed charges,,,2.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.62,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.42,,,fee schedule,,,4.42,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,2.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.15,,,percent of total billed charges,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,,,,,,,2.61,,,percent of total billed charges,,,548.68,,,per diem,,,4.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.42,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,1.64,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,4.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.35,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,4.11,,,percent of total billed charges,,,,,,,,,,,,,,,4.11,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.6,,,percent of total billed charges,,
DILTIAZEM CD 180 MG CAPCR,2500009972,CDM,637,RC,6050500156,NDC,999,EAPG,,,,outpatient,facility,180,UN,4.42,4.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM CD 240 MG CAPCR,2500009974,CDM,637,RC,6050500166,NDC,,,,,,inpatient,facility,240,UN,4.72,4.72,0.38,4.72,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,4.72,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.83,,,percent of total billed charges,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,4.01,,,percent of total billed charges,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.78,,,percent of total billed charges,,
DILTIAZEM CD 240 MG CAPCR,2500009974,CDM,637,RC,6050500166,NDC,,,,,,outpatient,facility,240,UN,4.72,4.72,0.38,548.68,,3.35,,,percent of total billed charges,,,1.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.72,,,percent of total billed charges,,,2.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.72,,,fee schedule,,,4.72,,,percent of total billed charges,,,,,,,,,4.72,,,percent of total billed charges,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,2.45,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,,,,,,,2.78,,,percent of total billed charges,,,548.68,,,per diem,,,4.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.72,,,percent of total billed charges,,,4.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.18,,,percent of total billed charges,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,4.72,,,percent of total billed charges,,,4.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.38,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,4.39,,,percent of total billed charges,,,,,,,,,,,,,,,4.39,,,percent of total billed charges,,,4.39,,,percent of total billed charges,,,4.39,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.78,,,percent of total billed charges,,
DILTIAZEM CD 240 MG CAPCR,2500009974,CDM,637,RC,6050500166,NDC,999,EAPG,,,,outpatient,facility,240,UN,4.72,4.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM CD 300 MG CAPCR,2500009976,CDM,637,RC,6838259816,NDC,,,,,,inpatient,facility,300,UN,8.78,8.78,0.7,8.78,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,,,,,,,8.78,,,percent of total billed charges,,,4.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,percent of total billed charges,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,4.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,8.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,
DILTIAZEM CD 300 MG CAPCR,2500009976,CDM,637,RC,6838259816,NDC,,,,,,outpatient,facility,300,UN,8.78,8.78,0.7,548.68,,6.23,,,percent of total billed charges,,,2.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.78,,,percent of total billed charges,,,5.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.21,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.78,,,fee schedule,,,8.78,,,percent of total billed charges,,,,,,,,,8.78,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.26,,,percent of total billed charges,,,,,,,,,,,,,,,4.74,,,percent of total billed charges,,,4.57,,,percent of total billed charges,,,4.83,,,percent of total billed charges,,,,,,,,,5.18,,,percent of total billed charges,,,548.68,,,per diem,,,8.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.78,,,percent of total billed charges,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.66,,,percent of total billed charges,,,8.78,,,percent of total billed charges,,,8.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.92,,,percent of total billed charges,,,7.1,,,percent of total billed charges,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,,,,,,,3.25,,,percent of total billed charges,,,3.25,,,percent of total billed charges,,,,,,,,,8.78,,,percent of total billed charges,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.7,,,percent of total billed charges,,,8.78,,,percent of total billed charges,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,8.78,,,percent of total billed charges,,,,,,,,,8.17,,,percent of total billed charges,,,,,,,,,,,,,,,8.17,,,percent of total billed charges,,,8.17,,,percent of total billed charges,,,8.17,,,percent of total billed charges,,,6.58,,,percent of total billed charges,,,8.78,,,percent of total billed charges,,,8.78,,,percent of total billed charges,,,8.78,,,percent of total billed charges,,,,,,,,,6.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.17,,,percent of total billed charges,,
DILTIAZEM CD 300 MG CAPCR,2500009976,CDM,637,RC,6838259816,NDC,999,EAPG,,,,outpatient,facility,300,UN,8.78,8.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM HCL 25 MG/5 ML INJ,2500009982,CDM,250,RC,J3490,HCPCS,7086030105,NDC,,,,inpatient,facility,5,UN,10.73,10.73,0.86,10.73,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,,,,,,,10.73,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.44,,,percent of total billed charges,,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,9.12,,,percent of total billed charges,,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,5.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,10.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.32,,,percent of total billed charges,,
DILTIAZEM HCL 25 MG/5 ML INJ,2500009982,CDM,250,RC,J3490,HCPCS,7086030105,NDC,,,,outpatient,facility,5,UN,10.73,10.73,0.86,548.68,,7.61,,,percent of total billed charges,,,2.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.73,,,percent of total billed charges,,,6.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.93,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,10.73,,,fee schedule,,,10.73,,,percent of total billed charges,,,,,,,,,10.73,,,percent of total billed charges,,,6.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.65,,,percent of total billed charges,,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,10.73,,,percent of total billed charges,,,10.73,,,percent of total billed charges,,,,,,,,,6.33,,,percent of total billed charges,,,548.68,,,per diem,,,10.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.73,,,percent of total billed charges,,,9.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.24,,,percent of total billed charges,,,8.68,,,percent of total billed charges,,,,,,,,,,,,,,,4.29,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10.73,,,percent of total billed charges,,,10.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.86,,,percent of total billed charges,,,10.73,,,percent of total billed charges,,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,10.73,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,8.05,,,percent of total billed charges,,,10.73,,,percent of total billed charges,,,10.73,,,percent of total billed charges,,,10.73,,,percent of total billed charges,,,,,,,,,7.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.37,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.32,,,percent of total billed charges,,
DILTIAZEM HCL 25 MG/5 ML INJ,2500009982,CDM,250,RC,J3490,HCPCS,7086030105,NDC,435,EAPG,,outpatient,facility,5,UN,10.73,10.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM HCL 30 MG TAB,2500009983,CDM,637,RC,93031801,NDC,,,,,,inpatient,facility,30,UN,3.3,3.3,0.26,3.3,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,3.3,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,
DILTIAZEM HCL 30 MG TAB,2500009983,CDM,637,RC,93031801,NDC,,,,,,outpatient,facility,30,UN,3.3,3.3,0.26,548.68,,2.34,,,percent of total billed charges,,,0.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.3,,,percent of total billed charges,,,2.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.21,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.3,,,fee schedule,,,3.3,,,percent of total billed charges,,,,,,,,,3.3,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,1.95,,,percent of total billed charges,,,548.68,,,per diem,,,3.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.3,,,percent of total billed charges,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,3.3,,,percent of total billed charges,,,3.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.94,,,percent of total billed charges,,
DILTIAZEM HCL 30 MG TAB,2500009983,CDM,637,RC,93031801,NDC,999,EAPG,,,,outpatient,facility,30,UN,3.3,3.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM HCL 125 MG/25ML INJ,2500009986,CDM,250,RC,J3490,HCPCS,7086030125,NDC,,,,inpatient,facility,25,UN,32.18,32.18,2.57,32.18,,,,,,,,,,,,,,32.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.18,,,percent of total billed charges,,,,,,,,,32.18,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.31,,,percent of total billed charges,,,,,,,,,,,,,,,32.18,,,percent of total billed charges,,,27.35,,,percent of total billed charges,,,,,,,,,,,,,,,32.18,,,percent of total billed charges,,,17.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,32.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,32.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.96,,,percent of total billed charges,,
DILTIAZEM HCL 125 MG/25ML INJ,2500009986,CDM,250,RC,J3490,HCPCS,7086030125,NDC,,,,outpatient,facility,25,UN,32.18,32.18,1.2,548.68,,22.82,,,percent of total billed charges,,,7.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,32.18,,,percent of total billed charges,,,20.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,22.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,22.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,32.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.78,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,32.18,,,fee schedule,,,32.18,,,percent of total billed charges,,,,,,,,,32.18,,,percent of total billed charges,,,19.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.93,,,percent of total billed charges,,,,,,,,,,,,,,,32.18,,,percent of total billed charges,,,32.18,,,percent of total billed charges,,,32.18,,,percent of total billed charges,,,,,,,,,18.99,,,percent of total billed charges,,,548.68,,,per diem,,,32.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,32.18,,,percent of total billed charges,,,27.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.09,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.71,,,percent of total billed charges,,,26.04,,,percent of total billed charges,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,32.18,,,percent of total billed charges,,,32.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,32.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.57,,,percent of total billed charges,,,32.18,,,percent of total billed charges,,,,,,,,,,,,,,,32.18,,,percent of total billed charges,,,32.18,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,24.13,,,percent of total billed charges,,,32.18,,,percent of total billed charges,,,32.18,,,percent of total billed charges,,,32.18,,,percent of total billed charges,,,,,,,,,22.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.96,,,percent of total billed charges,,
DILTIAZEM HCL 125 MG/25ML INJ,2500009986,CDM,250,RC,J3490,HCPCS,7086030125,NDC,435,EAPG,,outpatient,facility,25,UN,32.18,32.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM HCL 50 MG/10 ML INJ,2500009987,CDM,250,RC,J3490,HCPCS,1747893710,NDC,,,,inpatient,facility,10,UN,12.01,12.01,0.96,12.01,,,,,,,,,,,,,,12.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.01,,,percent of total billed charges,,,,,,,,,12.01,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.21,,,percent of total billed charges,,,,,,,,,,,,,,,12.01,,,percent of total billed charges,,,10.21,,,percent of total billed charges,,,,,,,,,,,,,,,12.01,,,percent of total billed charges,,,6.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,12.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.08,,,percent of total billed charges,,
DILTIAZEM HCL 50 MG/10 ML INJ,2500009987,CDM,250,RC,J3490,HCPCS,1747893710,NDC,,,,outpatient,facility,10,UN,12.01,12.01,0.96,548.68,,8.52,,,percent of total billed charges,,,2.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,12.01,,,percent of total billed charges,,,7.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,12.01,,,fee schedule,,,12.01,,,percent of total billed charges,,,,,,,,,12.01,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.56,,,percent of total billed charges,,,,,,,,,,,,,,,12.01,,,percent of total billed charges,,,12.01,,,percent of total billed charges,,,12.01,,,percent of total billed charges,,,,,,,,,7.09,,,percent of total billed charges,,,548.68,,,per diem,,,12.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12.01,,,percent of total billed charges,,,10.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.38,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.1,,,percent of total billed charges,,,9.72,,,percent of total billed charges,,,,,,,,,,,,,,,4.8,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12.01,,,percent of total billed charges,,,12.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.96,,,percent of total billed charges,,,12.01,,,percent of total billed charges,,,,,,,,,,,,,,,12.01,,,percent of total billed charges,,,12.01,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,9.01,,,percent of total billed charges,,,12.01,,,percent of total billed charges,,,12.01,,,percent of total billed charges,,,12.01,,,percent of total billed charges,,,,,,,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.08,,,percent of total billed charges,,
DILTIAZEM HCL 50 MG/10 ML INJ,2500009987,CDM,250,RC,J3490,HCPCS,1747893710,NDC,435,EAPG,,outpatient,facility,10,UN,12.01,12.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM HCL 60 MG TAB,2500009988,CDM,637,RC,93031901,NDC,,,,,,inpatient,facility,60,UN,5.18,5.18,0.41,5.18,,,,,,,,,,,,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.18,,,percent of total billed charges,,,,,,,,,5.18,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.11,,,percent of total billed charges,,,,,,,,,,,,,,,5.18,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,5.18,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.05,,,percent of total billed charges,,
DILTIAZEM HCL 60 MG TAB,2500009988,CDM,637,RC,93031901,NDC,,,,,,outpatient,facility,60,UN,5.18,5.18,0.41,548.68,,3.67,,,percent of total billed charges,,,1.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.18,,,percent of total billed charges,,,3.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.9,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.18,,,fee schedule,,,5.18,,,percent of total billed charges,,,,,,,,,5.18,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.69,,,percent of total billed charges,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,,2.69,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,3.06,,,percent of total billed charges,,,548.68,,,per diem,,,5.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.18,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.49,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,2.07,,,percent of total billed charges,,,,,,,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,5.18,,,percent of total billed charges,,,5.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.41,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,5.18,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,,,,,,,4.82,,,percent of total billed charges,,,,,,,,,,,,,,,4.82,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,3.88,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,,,,,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.05,,,percent of total billed charges,,
DILTIAZEM HCL 60 MG TAB,2500009988,CDM,637,RC,93031901,NDC,999,EAPG,,,,outpatient,facility,60,UN,5.18,5.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM HCL 90 MG TAB,2500009989,CDM,637,RC,93032001,NDC,,,,,,inpatient,facility,90,UN,7.06,7.06,0.56,7.06,,,,,,,,,,,,,,7.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.06,,,percent of total billed charges,,,,,,,,,7.06,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.24,,,percent of total billed charges,,,,,,,,,,,,,,,7.06,,,percent of total billed charges,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,7.06,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.06,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,7.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,
DILTIAZEM HCL 90 MG TAB,2500009989,CDM,637,RC,93032001,NDC,,,,,,outpatient,facility,90,UN,7.06,7.06,0.56,548.68,,5.01,,,percent of total billed charges,,,1.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.06,,,percent of total billed charges,,,4.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.58,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.06,,,fee schedule,,,7.06,,,percent of total billed charges,,,,,,,,,7.06,,,percent of total billed charges,,,4.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,3.81,,,percent of total billed charges,,,3.67,,,percent of total billed charges,,,3.88,,,percent of total billed charges,,,,,,,,,4.17,,,percent of total billed charges,,,548.68,,,per diem,,,7.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.06,,,percent of total billed charges,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.75,,,percent of total billed charges,,,7.06,,,percent of total billed charges,,,7.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.76,,,percent of total billed charges,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,2.82,,,percent of total billed charges,,,,,,,,,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,7.06,,,percent of total billed charges,,,7.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,7.06,,,percent of total billed charges,,,,,,,,,,,,,,,7.06,,,percent of total billed charges,,,7.06,,,percent of total billed charges,,,,,,,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,5.29,,,percent of total billed charges,,,7.06,,,percent of total billed charges,,,7.06,,,percent of total billed charges,,,7.06,,,percent of total billed charges,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.16,,,percent of total billed charges,,
DILTIAZEM HCL 90 MG TAB,2500009989,CDM,637,RC,93032001,NDC,999,EAPG,,,,outpatient,facility,90,UN,7.06,7.06,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM SR 60 MG CAPCR,2500009990,CDM,637,RC,5107992420,NDC,,,,,,inpatient,facility,60,UN,13.1,13.1,1.05,13.1,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,,,,,,,13.1,,,percent of total billed charges,,,6.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,11.14,,,percent of total billed charges,,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,
DILTIAZEM SR 60 MG CAPCR,2500009990,CDM,637,RC,5107992420,NDC,,,,,,outpatient,facility,60,UN,13.1,13.1,1.05,548.68,,9.29,,,percent of total billed charges,,,3.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.1,,,percent of total billed charges,,,8.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.79,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.1,,,fee schedule,,,13.1,,,percent of total billed charges,,,,,,,,,13.1,,,percent of total billed charges,,,8.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.33,,,percent of total billed charges,,,,,,,,,,,,,,,7.07,,,percent of total billed charges,,,6.81,,,percent of total billed charges,,,7.21,,,percent of total billed charges,,,,,,,,,7.73,,,percent of total billed charges,,,548.68,,,per diem,,,13.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.1,,,percent of total billed charges,,,11.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.84,,,percent of total billed charges,,,10.6,,,percent of total billed charges,,,,,,,,,,,,,,,5.24,,,percent of total billed charges,,,,,,,,,4.85,,,percent of total billed charges,,,4.85,,,percent of total billed charges,,,,,,,,,13.1,,,percent of total billed charges,,,13.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.05,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,,,,,,,12.19,,,percent of total billed charges,,,,,,,,,,,,,,,12.19,,,percent of total billed charges,,,12.19,,,percent of total billed charges,,,12.19,,,percent of total billed charges,,,9.82,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,,,,,,,9.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.72,,,percent of total billed charges,,
DILTIAZEM SR 60 MG CAPCR,2500009990,CDM,637,RC,5107992420,NDC,999,EAPG,,,,outpatient,facility,60,UN,13.1,13.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM SR 90 MG CAPCR,2500009992,CDM,637,RC,378609001,NDC,,,,,,inpatient,facility,90,UN,11.94,11.94,0.96,11.94,,,,,,,,,,,,,,11.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.94,,,percent of total billed charges,,,,,,,,,11.94,,,percent of total billed charges,,,6.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,11.94,,,percent of total billed charges,,,10.15,,,percent of total billed charges,,,,,,,,,,,,,,,11.94,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11.94,,,percent of total billed charges,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,11.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.04,,,percent of total billed charges,,
DILTIAZEM SR 90 MG CAPCR,2500009992,CDM,637,RC,378609001,NDC,,,,,,outpatient,facility,90,UN,11.94,11.94,0.96,548.68,,8.47,,,percent of total billed charges,,,2.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,11.94,,,percent of total billed charges,,,7.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.37,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,11.94,,,fee schedule,,,11.94,,,percent of total billed charges,,,,,,,,,11.94,,,percent of total billed charges,,,7.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,6.45,,,percent of total billed charges,,,6.21,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,,,,,,,7.04,,,percent of total billed charges,,,548.68,,,per diem,,,11.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11.94,,,percent of total billed charges,,,10.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,11.94,,,percent of total billed charges,,,11.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,9.66,,,percent of total billed charges,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,11.94,,,percent of total billed charges,,,11.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.96,,,percent of total billed charges,,,11.94,,,percent of total billed charges,,,,,,,,,,,,,,,11.94,,,percent of total billed charges,,,11.94,,,percent of total billed charges,,,,,,,,,11.11,,,percent of total billed charges,,,,,,,,,,,,,,,11.11,,,percent of total billed charges,,,11.11,,,percent of total billed charges,,,11.11,,,percent of total billed charges,,,8.96,,,percent of total billed charges,,,11.94,,,percent of total billed charges,,,11.94,,,percent of total billed charges,,,11.94,,,percent of total billed charges,,,,,,,,,8.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.04,,,percent of total billed charges,,
DILTIAZEM SR 90 MG CAPCR,2500009992,CDM,637,RC,378609001,NDC,999,EAPG,,,,outpatient,facility,90,UN,11.94,11.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM-SR 120 MG CAP,2500009993,CDM,637,RC,6068719501,NDC,,,,,,inpatient,facility,120,UN,3.2,3.2,0.26,3.2,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,3.2,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,
DILTIAZEM-SR 120 MG CAP,2500009993,CDM,637,RC,6068719501,NDC,,,,,,outpatient,facility,120,UN,3.2,3.2,0.26,548.68,,2.27,,,percent of total billed charges,,,0.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.2,,,percent of total billed charges,,,2.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.17,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.2,,,fee schedule,,,3.2,,,percent of total billed charges,,,,,,,,,3.2,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,1.76,,,percent of total billed charges,,,,,,,,,1.89,,,percent of total billed charges,,,548.68,,,per diem,,,3.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.2,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,3.2,,,percent of total billed charges,,,3.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,2.98,,,percent of total billed charges,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.89,,,percent of total billed charges,,
DILTIAZEM-SR 120 MG CAP,2500009993,CDM,637,RC,6068719501,NDC,999,EAPG,,,,outpatient,facility,120,UN,3.2,3.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIPHENHYDRAMINE 25 MG CAP,2500010051,CDM,637,RC,904530661,NDC,,,,,,inpatient,facility,25,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
DIPHENHYDRAMINE 25 MG CAP,2500010051,CDM,637,RC,904530661,NDC,,,,,,outpatient,facility,25,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
DIPHENHYDRAMINE 25 MG CAP,2500010051,CDM,637,RC,904530661,NDC,999,EAPG,,,,outpatient,facility,25,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIPHENHYDRAMINE 25 MG/10 ML UD,2500010057,CDM,637,RC,121097800,NDC,,,,,,inpatient,facility,10,UN,14.88,14.88,1.19,14.88,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,,,,,,,14.88,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.93,,,percent of total billed charges,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,12.65,,,percent of total billed charges,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,7.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.77,,,percent of total billed charges,,
DIPHENHYDRAMINE 25 MG/10 ML UD,2500010057,CDM,637,RC,121097800,NDC,,,,,,outpatient,facility,10,UN,14.88,14.88,1.19,548.68,,10.55,,,percent of total billed charges,,,3.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.88,,,percent of total billed charges,,,9.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.45,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.88,,,fee schedule,,,14.88,,,percent of total billed charges,,,,,,,,,14.88,,,percent of total billed charges,,,9.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.6,,,percent of total billed charges,,,,,,,,,,,,,,,8.04,,,percent of total billed charges,,,7.74,,,percent of total billed charges,,,8.18,,,percent of total billed charges,,,,,,,,,8.78,,,percent of total billed charges,,,548.68,,,per diem,,,14.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.88,,,percent of total billed charges,,,12.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.9,,,percent of total billed charges,,,14.88,,,percent of total billed charges,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.04,,,percent of total billed charges,,,12.04,,,percent of total billed charges,,,,,,,,,,,,,,,5.95,,,percent of total billed charges,,,,,,,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,14.88,,,percent of total billed charges,,,14.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.19,,,percent of total billed charges,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,14.88,,,percent of total billed charges,,,,,,,,,13.84,,,percent of total billed charges,,,,,,,,,,,,,,,13.84,,,percent of total billed charges,,,13.84,,,percent of total billed charges,,,13.84,,,percent of total billed charges,,,11.16,,,percent of total billed charges,,,14.88,,,percent of total billed charges,,,14.88,,,percent of total billed charges,,,14.88,,,percent of total billed charges,,,,,,,,,10.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.77,,,percent of total billed charges,,
DIPHENHYDRAMINE 25 MG/10 ML UD,2500010057,CDM,637,RC,121097800,NDC,999,EAPG,,,,outpatient,facility,10,UN,14.88,14.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIPHENOXYLATE/ATR 2.5 MG TAB,2500010070,CDM,637,RC,5976210611,NDC,,,,,,inpatient,facility,1,UN,1.35,1.35,0.11,1.35,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,
DIPHENOXYLATE/ATR 2.5 MG TAB,2500010070,CDM,637,RC,5976210611,NDC,,,,,,outpatient,facility,1,UN,1.35,1.35,0.11,548.68,,0.96,,,percent of total billed charges,,,0.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.35,,,percent of total billed charges,,,0.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.35,,,fee schedule,,,1.35,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,0.8,,,percent of total billed charges,,,548.68,,,per diem,,,1.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.35,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.8,,,percent of total billed charges,,
DIPHENOXYLATE/ATR 2.5 MG TAB,2500010070,CDM,637,RC,5976210611,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.35,1.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIPYRIDAMOLE 25 MG TAB,2500010090,CDM,637,RC,6498013301,NDC,,,,,,inpatient,facility,25,UN,4.68,4.68,0.37,4.68,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,2.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,
DIPYRIDAMOLE 25 MG TAB,2500010090,CDM,637,RC,6498013301,NDC,,,,,,outpatient,facility,25,UN,4.68,4.68,0.37,548.68,,3.32,,,percent of total billed charges,,,1.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.68,,,percent of total billed charges,,,2.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.68,,,fee schedule,,,4.68,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,2.76,,,percent of total billed charges,,,548.68,,,per diem,,,4.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.68,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,1.73,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.37,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,4.35,,,percent of total billed charges,,,,,,,,,,,,,,,4.35,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.76,,,percent of total billed charges,,
DIPYRIDAMOLE 25 MG TAB,2500010090,CDM,637,RC,6498013301,NDC,999,EAPG,,,,outpatient,facility,25,UN,4.68,4.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIPYRIDAMOLE/ASA CR 200-25 MG,2500010095,CDM,637,RC,6846240560,NDC,,,,,,inpatient,facility,1,UN,27.59,27.59,2.21,27.59,,,,,,,,,,,,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.59,,,percent of total billed charges,,,,,,,,,27.59,,,percent of total billed charges,,,14.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.55,,,percent of total billed charges,,,,,,,,,,,,,,,27.59,,,percent of total billed charges,,,23.45,,,percent of total billed charges,,,,,,,,,,,,,,,27.59,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.26,,,percent of total billed charges,,
DIPYRIDAMOLE/ASA CR 200-25 MG,2500010095,CDM,637,RC,6846240560,NDC,,,,,,outpatient,facility,1,UN,27.59,27.59,2.21,548.68,,19.56,,,percent of total billed charges,,,6.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,27.59,,,percent of total billed charges,,,17.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,19.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,19.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,27.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,27.59,,,fee schedule,,,27.59,,,percent of total billed charges,,,,,,,,,27.59,,,percent of total billed charges,,,16.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.66,,,percent of total billed charges,,,,,,,,,,,,,,,14.9,,,percent of total billed charges,,,14.35,,,percent of total billed charges,,,15.17,,,percent of total billed charges,,,,,,,,,16.28,,,percent of total billed charges,,,548.68,,,per diem,,,27.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,27.59,,,percent of total billed charges,,,23.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.61,,,percent of total billed charges,,,22.33,,,percent of total billed charges,,,,,,,,,,,,,,,11.04,,,percent of total billed charges,,,,,,,,,10.21,,,percent of total billed charges,,,10.21,,,percent of total billed charges,,,,,,,,,27.59,,,percent of total billed charges,,,27.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.21,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,27.59,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,,,,,,,25.66,,,percent of total billed charges,,,,,,,,,,,,,,,25.66,,,percent of total billed charges,,,25.66,,,percent of total billed charges,,,25.66,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,,,,,,,19.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.79,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,16.26,,,percent of total billed charges,,
DIPYRIDAMOLE/ASA CR 200-25 MG,2500010095,CDM,637,RC,6846240560,NDC,999,EAPG,,,,outpatient,facility,1,UN,27.59,27.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DISOPYRAMIDE 100 MG CAP,2500010100,CDM,637,RC,93312701,NDC,,,,,,inpatient,facility,100,UN,9.44,9.44,0.76,9.44,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,9.44,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.66,,,percent of total billed charges,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,8.02,,,percent of total billed charges,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.56,,,percent of total billed charges,,
DISOPYRAMIDE 100 MG CAP,2500010100,CDM,637,RC,93312701,NDC,,,,,,outpatient,facility,100,UN,9.44,9.44,0.76,548.68,,6.69,,,percent of total billed charges,,,2.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.44,,,percent of total billed charges,,,5.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.44,,,fee schedule,,,9.44,,,percent of total billed charges,,,,,,,,,9.44,,,percent of total billed charges,,,5.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.73,,,percent of total billed charges,,,,,,,,,,,,,,,5.1,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,5.19,,,percent of total billed charges,,,,,,,,,5.57,,,percent of total billed charges,,,548.68,,,per diem,,,9.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.44,,,percent of total billed charges,,,8.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.37,,,percent of total billed charges,,,7.64,,,percent of total billed charges,,,,,,,,,,,,,,,3.78,,,percent of total billed charges,,,,,,,,,3.49,,,percent of total billed charges,,,3.49,,,percent of total billed charges,,,,,,,,,9.44,,,percent of total billed charges,,,9.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.76,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,9.44,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,8.78,,,percent of total billed charges,,,,,,,,,,,,,,,8.78,,,percent of total billed charges,,,8.78,,,percent of total billed charges,,,8.78,,,percent of total billed charges,,,7.08,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,6.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.56,,,percent of total billed charges,,
DISOPYRAMIDE 100 MG CAP,2500010100,CDM,637,RC,93312701,NDC,999,EAPG,,,,outpatient,facility,100,UN,9.44,9.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DISULFIRAM 250 MG TAB,2500010110,CDM,637,RC,4778160730,NDC,,,,,,inpatient,facility,250,UN,13.33,13.33,1.07,13.33,,,,,,,,,,,,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.33,,,percent of total billed charges,,,,,,,,,13.33,,,percent of total billed charges,,,6.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8,,,percent of total billed charges,,,,,,,,,,,,,,,13.33,,,percent of total billed charges,,,11.33,,,percent of total billed charges,,,,,,,,,,,,,,,13.33,,,percent of total billed charges,,,7.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.85,,,percent of total billed charges,,
DISULFIRAM 250 MG TAB,2500010110,CDM,637,RC,4778160730,NDC,,,,,,outpatient,facility,250,UN,13.33,13.33,1.07,548.68,,9.45,,,percent of total billed charges,,,3.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.33,,,percent of total billed charges,,,8.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.88,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.33,,,fee schedule,,,13.33,,,percent of total billed charges,,,,,,,,,13.33,,,percent of total billed charges,,,8.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,7.2,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,7.33,,,percent of total billed charges,,,,,,,,,7.86,,,percent of total billed charges,,,548.68,,,per diem,,,13.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.33,,,percent of total billed charges,,,11.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.08,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.99,,,percent of total billed charges,,,10.79,,,percent of total billed charges,,,,,,,,,,,,,,,5.33,,,percent of total billed charges,,,,,,,,,4.93,,,percent of total billed charges,,,4.93,,,percent of total billed charges,,,,,,,,,13.33,,,percent of total billed charges,,,13.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.07,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,13.33,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,,,,,,,12.4,,,percent of total billed charges,,,,,,,,,,,,,,,12.4,,,percent of total billed charges,,,12.4,,,percent of total billed charges,,,12.4,,,percent of total billed charges,,,10,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,13.33,,,percent of total billed charges,,,,,,,,,9.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.67,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.85,,,percent of total billed charges,,
DISULFIRAM 250 MG TAB,2500010110,CDM,637,RC,4778160730,NDC,999,EAPG,,,,outpatient,facility,250,UN,13.33,13.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIVALPROEX  SOD 125 MG TAB-EC,2500010121,CDM,637,RC,6068721121,NDC,,,,,,inpatient,facility,125,UN,2.93,2.93,0.23,2.93,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,2.93,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,2.49,,,percent of total billed charges,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,
DIVALPROEX  SOD 125 MG TAB-EC,2500010121,CDM,637,RC,6068721121,NDC,,,,,,outpatient,facility,125,UN,2.93,2.93,0.23,548.68,,2.08,,,percent of total billed charges,,,0.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.93,,,percent of total billed charges,,,1.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.07,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.93,,,fee schedule,,,2.93,,,percent of total billed charges,,,,,,,,,2.93,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,1.73,,,percent of total billed charges,,,548.68,,,per diem,,,2.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.93,,,percent of total billed charges,,,2.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,2.93,,,percent of total billed charges,,,2.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,2.2,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.73,,,percent of total billed charges,,
DIVALPROEX  SOD 125 MG TAB-EC,2500010121,CDM,637,RC,6068721121,NDC,999,EAPG,,,,outpatient,facility,125,UN,2.93,2.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIVALPROEX  SOD 250 MG TABEC,2500010122,CDM,637,RC,904686061,NDC,,,,,,inpatient,facility,250,UN,0.66,0.66,0.05,0.66,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,
DIVALPROEX  SOD 250 MG TABEC,2500010122,CDM,637,RC,904686061,NDC,,,,,,outpatient,facility,250,UN,0.66,0.66,0.05,548.68,,0.47,,,percent of total billed charges,,,0.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.66,,,percent of total billed charges,,,0.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.24,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.66,,,fee schedule,,,0.66,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,548.68,,,per diem,,,0.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.66,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,0.24,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.39,,,percent of total billed charges,,
DIVALPROEX  SOD 250 MG TABEC,2500010122,CDM,637,RC,904686061,NDC,999,EAPG,,,,outpatient,facility,250,UN,0.66,0.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIVALPROEX  SOD 500 MG TABEC,2500010125,CDM,637,RC,832712401,NDC,,,,,,inpatient,facility,500,UN,4.68,4.68,0.37,4.68,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,2.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,
DIVALPROEX  SOD 500 MG TABEC,2500010125,CDM,637,RC,832712401,NDC,,,,,,outpatient,facility,500,UN,4.68,4.68,0.37,548.68,,3.32,,,percent of total billed charges,,,1.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.68,,,percent of total billed charges,,,2.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.68,,,fee schedule,,,4.68,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,2.76,,,percent of total billed charges,,,548.68,,,per diem,,,4.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.68,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,1.73,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.37,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,4.35,,,percent of total billed charges,,,,,,,,,,,,,,,4.35,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.76,,,percent of total billed charges,,
DIVALPROEX  SOD 500 MG TABEC,2500010125,CDM,637,RC,832712401,NDC,999,EAPG,,,,outpatient,facility,500,UN,4.68,4.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIVALPROEX  SOD 125MG SPRINKLE,2500010126,CDM,637,RC,904661561,NDC,,,,,,inpatient,facility,125,UN,2.93,2.93,0.23,2.93,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,2.93,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,2.49,,,percent of total billed charges,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,
DIVALPROEX  SOD 125MG SPRINKLE,2500010126,CDM,637,RC,904661561,NDC,,,,,,outpatient,facility,125,UN,2.93,2.93,0.23,548.68,,2.08,,,percent of total billed charges,,,0.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.93,,,percent of total billed charges,,,1.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.07,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.93,,,fee schedule,,,2.93,,,percent of total billed charges,,,,,,,,,2.93,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,1.73,,,percent of total billed charges,,,548.68,,,per diem,,,2.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.93,,,percent of total billed charges,,,2.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,2.93,,,percent of total billed charges,,,2.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,2.2,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.73,,,percent of total billed charges,,
DIVALPROEX  SOD 125MG SPRINKLE,2500010126,CDM,637,RC,904661561,NDC,999,EAPG,,,,outpatient,facility,125,UN,2.93,2.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOCUSATE/SENNA TAB,2500010145,CDM,637,RC,536124801,NDC,,,,,,inpatient,facility,1,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
DOCUSATE/SENNA TAB,2500010145,CDM,637,RC,536124801,NDC,,,,,,outpatient,facility,1,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
DOCUSATE/SENNA TAB,2500010145,CDM,637,RC,536124801,NDC,999,EAPG,,,,outpatient,facility,1,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOCUSATE  SOD 100 MG/10 ML UDC,2500010155,CDM,637,RC,5038377111,NDC,,,,,,inpatient,facility,10,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
DOCUSATE  SOD 100 MG/10 ML UDC,2500010155,CDM,637,RC,5038377111,NDC,,,,,,outpatient,facility,10,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
DOCUSATE  SOD 100 MG/10 ML UDC,2500010155,CDM,637,RC,5038377111,NDC,999,EAPG,,,,outpatient,facility,10,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOFETILIDE 125 MCG CAP,2500010170,CDM,637,RC,4733506186,NDC,,,,,,inpatient,facility,125,UN,28.25,28.25,2.26,28.25,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,,,,,,,28.25,,,percent of total billed charges,,,14.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.95,,,percent of total billed charges,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,24.01,,,percent of total billed charges,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.64,,,percent of total billed charges,,
DOFETILIDE 125 MCG CAP,2500010170,CDM,637,RC,4733506186,NDC,,,,,,outpatient,facility,125,UN,28.25,28.25,2.26,548.68,,20.03,,,percent of total billed charges,,,6.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,28.25,,,percent of total billed charges,,,17.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,19.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,19.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.34,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,28.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,28.25,,,fee schedule,,,28.25,,,percent of total billed charges,,,,,,,,,28.25,,,percent of total billed charges,,,17.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,15.26,,,percent of total billed charges,,,14.69,,,percent of total billed charges,,,15.54,,,percent of total billed charges,,,,,,,,,16.67,,,percent of total billed charges,,,548.68,,,per diem,,,28.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,28.25,,,percent of total billed charges,,,24.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.06,,,percent of total billed charges,,,22.86,,,percent of total billed charges,,,,,,,,,,,,,,,11.3,,,percent of total billed charges,,,,,,,,,10.45,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,,,,,,,28.25,,,percent of total billed charges,,,28.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.26,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,,,,,,,26.28,,,percent of total billed charges,,,,,,,,,,,,,,,26.28,,,percent of total billed charges,,,26.28,,,percent of total billed charges,,,26.28,,,percent of total billed charges,,,21.19,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,,,,,,,19.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,16.64,,,percent of total billed charges,,
DOFETILIDE 125 MCG CAP,2500010170,CDM,637,RC,4733506186,NDC,999,EAPG,,,,outpatient,facility,125,UN,28.25,28.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOFETILIDE 250 MCG CAP,2500010172,CDM,637,RC,4733506286,NDC,,,,,,inpatient,facility,250,UN,28.25,28.25,2.26,28.25,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,,,,,,,28.25,,,percent of total billed charges,,,14.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.95,,,percent of total billed charges,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,24.01,,,percent of total billed charges,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.64,,,percent of total billed charges,,
DOFETILIDE 250 MCG CAP,2500010172,CDM,637,RC,4733506286,NDC,,,,,,outpatient,facility,250,UN,28.25,28.25,2.26,548.68,,20.03,,,percent of total billed charges,,,6.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,28.25,,,percent of total billed charges,,,17.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,19.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,19.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.34,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,28.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,28.25,,,fee schedule,,,28.25,,,percent of total billed charges,,,,,,,,,28.25,,,percent of total billed charges,,,17.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,15.26,,,percent of total billed charges,,,14.69,,,percent of total billed charges,,,15.54,,,percent of total billed charges,,,,,,,,,16.67,,,percent of total billed charges,,,548.68,,,per diem,,,28.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,28.25,,,percent of total billed charges,,,24.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.06,,,percent of total billed charges,,,22.86,,,percent of total billed charges,,,,,,,,,,,,,,,11.3,,,percent of total billed charges,,,,,,,,,10.45,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,,,,,,,28.25,,,percent of total billed charges,,,28.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.26,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,,,,,,,26.28,,,percent of total billed charges,,,,,,,,,,,,,,,26.28,,,percent of total billed charges,,,26.28,,,percent of total billed charges,,,26.28,,,percent of total billed charges,,,21.19,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,,,,,,,19.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,16.64,,,percent of total billed charges,,
DOFETILIDE 250 MCG CAP,2500010172,CDM,637,RC,4733506286,NDC,999,EAPG,,,,outpatient,facility,250,UN,28.25,28.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOFETILIDE 500 MCG CAP,2500010175,CDM,637,RC,4733506386,NDC,,,,,,inpatient,facility,500,UN,28.25,28.25,2.26,28.25,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,,,,,,,28.25,,,percent of total billed charges,,,14.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.95,,,percent of total billed charges,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,24.01,,,percent of total billed charges,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.64,,,percent of total billed charges,,
DOFETILIDE 500 MCG CAP,2500010175,CDM,637,RC,4733506386,NDC,,,,,,outpatient,facility,500,UN,28.25,28.25,2.26,548.68,,20.03,,,percent of total billed charges,,,6.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,28.25,,,percent of total billed charges,,,17.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,19.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,19.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.34,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,28.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,28.25,,,fee schedule,,,28.25,,,percent of total billed charges,,,,,,,,,28.25,,,percent of total billed charges,,,17.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,15.26,,,percent of total billed charges,,,14.69,,,percent of total billed charges,,,15.54,,,percent of total billed charges,,,,,,,,,16.67,,,percent of total billed charges,,,548.68,,,per diem,,,28.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,28.25,,,percent of total billed charges,,,24.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.06,,,percent of total billed charges,,,22.86,,,percent of total billed charges,,,,,,,,,,,,,,,11.3,,,percent of total billed charges,,,,,,,,,10.45,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,,,,,,,28.25,,,percent of total billed charges,,,28.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.26,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,,,,,,,26.28,,,percent of total billed charges,,,,,,,,,,,,,,,26.28,,,percent of total billed charges,,,26.28,,,percent of total billed charges,,,26.28,,,percent of total billed charges,,,21.19,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,28.25,,,percent of total billed charges,,,,,,,,,19.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,16.64,,,percent of total billed charges,,
DOFETILIDE 500 MCG CAP,2500010175,CDM,637,RC,4733506386,NDC,999,EAPG,,,,outpatient,facility,500,UN,28.25,28.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DONEPEZIL HCL 5 MG TAB,2500010192,CDM,637,RC,904647761,NDC,,,,,,inpatient,facility,5,UN,0.46,0.46,0.04,0.46,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,
DONEPEZIL HCL 5 MG TAB,2500010192,CDM,637,RC,904647761,NDC,,,,,,outpatient,facility,5,UN,0.46,0.46,0.04,548.68,,0.33,,,percent of total billed charges,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,0.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.17,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.46,,,fee schedule,,,0.46,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,0.27,,,percent of total billed charges,,,548.68,,,per diem,,,0.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.46,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,0.17,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.27,,,percent of total billed charges,,
DONEPEZIL HCL 5 MG TAB,2500010192,CDM,637,RC,904647761,NDC,999,EAPG,,,,outpatient,facility,5,UN,0.46,0.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOPAMINE 400MG/250 ML,2500010212,CDM,636,RC,J1265,HCPCS,338100702,NDC,,,,inpatient,facility,250,UN,46.86,46.86,3.75,46.86,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,,,,46.86,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.12,,,percent of total billed charges,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,39.83,,,percent of total billed charges,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,24.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,3.75,,,percent of total billed charges,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.61,,,percent of total billed charges,,
DOPAMINE 400MG/250 ML,2500010212,CDM,636,RC,J1265,HCPCS,338100702,NDC,,,,outpatient,facility,250,UN,46.86,46.86,0.81,548.68,,33.23,,,percent of total billed charges,,,11.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,46.86,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,17.15,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,46.86,,,fee schedule,,,46.86,,,percent of total billed charges,,,,,,,,,46.86,,,percent of total billed charges,,,28.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,27.65,,,percent of total billed charges,,,548.68,,,per diem,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,46.86,,,percent of total billed charges,,,39.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.89,,,percent of total billed charges,,,46.86,,,percent of total billed charges,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.61,,,percent of total billed charges,,,37.92,,,percent of total billed charges,,,,,,,,,,,,,,,18.74,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,46.86,,,percent of total billed charges,,,46.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.75,,,percent of total billed charges,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.81,,,fee schedule,,,46.86,,,percent of total billed charges,,,46.86,,,percent of total billed charges,,,46.86,,,percent of total billed charges,,,,,,,,,32.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,27.61,,,percent of total billed charges,,
DOPAMINE 400MG/250 ML,2500010212,CDM,636,RC,J1265,HCPCS,338100702,NDC,999,EAPG,,outpatient,facility,250,UN,46.86,46.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DORZOLAMIDE/TIMOL 2 -0.5  10ML,2500010226,CDM,637,RC,2420848610,NDC,,,,,,inpatient,facility,10,UN,222.72,222.72,17.82,222.72,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,,,,,,,222.72,,,percent of total billed charges,,,113.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.63,,,percent of total billed charges,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,189.31,,,percent of total billed charges,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,118.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.23,,,percent of total billed charges,,
DORZOLAMIDE/TIMOL 2 -0.5  10ML,2500010226,CDM,637,RC,2420848610,NDC,,,,,,outpatient,facility,10,UN,222.72,222.72,17.82,548.68,,157.93,,,percent of total billed charges,,,54.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,222.72,,,percent of total billed charges,,,139.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,156.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,156.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,81.52,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,222.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,222.72,,,fee schedule,,,222.72,,,percent of total billed charges,,,,,,,,,222.72,,,percent of total billed charges,,,136.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.69,,,percent of total billed charges,,,,,,,,,,,,,,,120.27,,,percent of total billed charges,,,115.81,,,percent of total billed charges,,,122.5,,,percent of total billed charges,,,,,,,,,131.4,,,percent of total billed charges,,,548.68,,,per diem,,,222.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,222.72,,,percent of total billed charges,,,189.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,118.29,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.25,,,percent of total billed charges,,,180.23,,,percent of total billed charges,,,,,,,,,,,,,,,89.09,,,percent of total billed charges,,,,,,,,,82.41,,,percent of total billed charges,,,82.41,,,percent of total billed charges,,,,,,,,,222.72,,,percent of total billed charges,,,222.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,222.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.82,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,,,,,,,207.17,,,percent of total billed charges,,,,,,,,,,,,,,,207.17,,,percent of total billed charges,,,207.17,,,percent of total billed charges,,,207.17,,,percent of total billed charges,,,167.04,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,,,,,,,156.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,131.23,,,percent of total billed charges,,
DORZOLAMIDE/TIMOL 2 -0.5  10ML,2500010226,CDM,637,RC,2420848610,NDC,999,EAPG,,,,outpatient,facility,10,UN,222.72,222.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXAZOSIN MESY 1 MG TAB,2500010240,CDM,637,RC,1672921101,NDC,,,,,,inpatient,facility,1,UN,4.45,4.45,0.36,4.45,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,,,,,,,4.45,,,percent of total billed charges,,,2.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,3.78,,,percent of total billed charges,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,
DOXAZOSIN MESY 1 MG TAB,2500010240,CDM,637,RC,1672921101,NDC,,,,,,outpatient,facility,1,UN,4.45,4.45,0.36,548.68,,3.16,,,percent of total billed charges,,,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.45,,,percent of total billed charges,,,2.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.45,,,fee schedule,,,4.45,,,percent of total billed charges,,,,,,,,,4.45,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.45,,,percent of total billed charges,,,,,,,,,2.63,,,percent of total billed charges,,,548.68,,,per diem,,,4.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.45,,,percent of total billed charges,,,3.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,1.65,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,4.45,,,percent of total billed charges,,,4.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.36,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,4.14,,,percent of total billed charges,,,,,,,,,,,,,,,4.14,,,percent of total billed charges,,,4.14,,,percent of total billed charges,,,4.14,,,percent of total billed charges,,,3.34,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,3.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.62,,,percent of total billed charges,,
DOXAZOSIN MESY 1 MG TAB,2500010240,CDM,637,RC,1672921101,NDC,999,EAPG,,,,outpatient,facility,1,UN,4.45,4.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXAZOSIN MESY 2 MG TAB,2500010242,CDM,637,RC,1672941401,NDC,,,,,,inpatient,facility,2,UN,4.46,4.46,0.36,4.46,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,4.46,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.63,,,percent of total billed charges,,
DOXAZOSIN MESY 2 MG TAB,2500010242,CDM,637,RC,1672941401,NDC,,,,,,outpatient,facility,2,UN,4.46,4.46,0.36,548.68,,3.16,,,percent of total billed charges,,,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.46,,,percent of total billed charges,,,2.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.46,,,fee schedule,,,4.46,,,percent of total billed charges,,,,,,,,,4.46,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,2.32,,,percent of total billed charges,,,2.45,,,percent of total billed charges,,,,,,,,,2.63,,,percent of total billed charges,,,548.68,,,per diem,,,4.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.46,,,percent of total billed charges,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,,3.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,1.65,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,4.46,,,percent of total billed charges,,,4.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.36,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,4.15,,,percent of total billed charges,,,,,,,,,,,,,,,4.15,,,percent of total billed charges,,,4.15,,,percent of total billed charges,,,4.15,,,percent of total billed charges,,,3.34,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.63,,,percent of total billed charges,,
DOXAZOSIN MESY 2 MG TAB,2500010242,CDM,637,RC,1672941401,NDC,999,EAPG,,,,outpatient,facility,2,UN,4.46,4.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXAZOSIN MESY 4 MG TAB,2500010244,CDM,637,RC,1672921301,NDC,,,,,,inpatient,facility,4,UN,4.68,4.68,0.37,4.68,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,2.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,
DOXAZOSIN MESY 4 MG TAB,2500010244,CDM,637,RC,1672921301,NDC,,,,,,outpatient,facility,4,UN,4.68,4.68,0.37,548.68,,3.32,,,percent of total billed charges,,,1.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.68,,,percent of total billed charges,,,2.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.68,,,fee schedule,,,4.68,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,2.76,,,percent of total billed charges,,,548.68,,,per diem,,,4.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.68,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,1.73,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.37,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,4.35,,,percent of total billed charges,,,,,,,,,,,,,,,4.35,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.76,,,percent of total billed charges,,
DOXAZOSIN MESY 4 MG TAB,2500010244,CDM,637,RC,1672921301,NDC,999,EAPG,,,,outpatient,facility,4,UN,4.68,4.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXEPIN HCL 10 MG CAP,2500010251,CDM,637,RC,904705261,NDC,,,,,,inpatient,facility,10,UN,2.01,2.01,0.16,2.01,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
DOXEPIN HCL 10 MG CAP,2500010251,CDM,637,RC,904705261,NDC,,,,,,outpatient,facility,10,UN,2.01,2.01,0.16,548.68,,1.43,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.01,,,percent of total billed charges,,,1.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.01,,,fee schedule,,,2.01,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,1.19,,,percent of total billed charges,,,548.68,,,per diem,,,2.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.01,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
DOXEPIN HCL 10 MG CAP,2500010251,CDM,637,RC,904705261,NDC,999,EAPG,,,,outpatient,facility,10,UN,2.01,2.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXEPIN HCL 25 MG CAP,2500010253,CDM,637,RC,904705361,NDC,,,,,,inpatient,facility,25,UN,2.64,2.64,0.21,2.64,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,
DOXEPIN HCL 25 MG CAP,2500010253,CDM,637,RC,904705361,NDC,,,,,,outpatient,facility,25,UN,2.64,2.64,0.21,548.68,,1.87,,,percent of total billed charges,,,0.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.64,,,percent of total billed charges,,,1.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.97,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.64,,,fee schedule,,,2.64,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,1.56,,,percent of total billed charges,,,548.68,,,per diem,,,2.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.64,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,0.98,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,2.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,1.98,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.56,,,percent of total billed charges,,
DOXEPIN HCL 25 MG CAP,2500010253,CDM,637,RC,904705361,NDC,999,EAPG,,,,outpatient,facility,25,UN,2.64,2.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXYCYCLINE HYCLATE 100 MG TAB,2500010272,CDM,637,RC,904043006,NDC,,,,,,inpatient,facility,100,UN,7.23,7.23,0.58,7.23,,,,,,,,,,,,,,7.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.23,,,percent of total billed charges,,,,,,,,,7.23,,,percent of total billed charges,,,3.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.34,,,percent of total billed charges,,,,,,,,,,,,,,,7.23,,,percent of total billed charges,,,6.15,,,percent of total billed charges,,,,,,,,,,,,,,,7.23,,,percent of total billed charges,,,3.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,7.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,
DOXYCYCLINE HYCLATE 100 MG TAB,2500010272,CDM,637,RC,904043006,NDC,,,,,,outpatient,facility,100,UN,7.23,7.23,0.58,548.68,,5.13,,,percent of total billed charges,,,1.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.23,,,percent of total billed charges,,,4.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.23,,,fee schedule,,,7.23,,,percent of total billed charges,,,,,,,,,7.23,,,percent of total billed charges,,,4.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,4.27,,,percent of total billed charges,,,548.68,,,per diem,,,7.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.23,,,percent of total billed charges,,,6.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.84,,,percent of total billed charges,,,7.23,,,percent of total billed charges,,,7.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.88,,,percent of total billed charges,,,5.85,,,percent of total billed charges,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,2.68,,,percent of total billed charges,,,2.68,,,percent of total billed charges,,,,,,,,,7.23,,,percent of total billed charges,,,7.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.58,,,percent of total billed charges,,,7.23,,,percent of total billed charges,,,,,,,,,,,,,,,7.23,,,percent of total billed charges,,,7.23,,,percent of total billed charges,,,,,,,,,6.73,,,percent of total billed charges,,,,,,,,,,,,,,,6.73,,,percent of total billed charges,,,6.73,,,percent of total billed charges,,,6.73,,,percent of total billed charges,,,5.42,,,percent of total billed charges,,,7.23,,,percent of total billed charges,,,7.23,,,percent of total billed charges,,,7.23,,,percent of total billed charges,,,,,,,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.62,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.26,,,percent of total billed charges,,
DOXYCYCLINE HYCLATE 100 MG TAB,2500010272,CDM,637,RC,904043006,NDC,999,EAPG,,,,outpatient,facility,100,UN,7.23,7.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXYCYCLINE HYCLATE 100 MG INJ,2500010274,CDM,250,RC,J3490,HCPCS,6838291010,NDC,,,,inpatient,facility,100,UN,99.66,99.66,7.97,99.66,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,,,,,,,99.66,,,percent of total billed charges,,,50.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.8,,,percent of total billed charges,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,84.71,,,percent of total billed charges,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,52.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,7.97,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.72,,,percent of total billed charges,,
DOXYCYCLINE HYCLATE 100 MG INJ,2500010274,CDM,250,RC,J3490,HCPCS,6838291010,NDC,,,,outpatient,facility,100,UN,99.66,99.66,1.2,548.68,,70.67,,,percent of total billed charges,,,24.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,99.66,,,percent of total billed charges,,,62.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,70.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,70.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,36.48,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,99.66,,,fee schedule,,,99.66,,,percent of total billed charges,,,,,,,,,99.66,,,percent of total billed charges,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.01,,,percent of total billed charges,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,,,,,,,58.8,,,percent of total billed charges,,,548.68,,,per diem,,,99.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,99.66,,,percent of total billed charges,,,84.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.93,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.23,,,percent of total billed charges,,,80.64,,,percent of total billed charges,,,,,,,,,,,,,,,39.86,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,99.66,,,percent of total billed charges,,,99.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,99.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.97,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,,99.66,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,74.75,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,99.66,,,percent of total billed charges,,,,,,,,,69.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,58.72,,,percent of total billed charges,,
DOXYCYCLINE HYCLATE 100 MG INJ,2500010274,CDM,250,RC,J3490,HCPCS,6838291010,NDC,435,EAPG,,outpatient,facility,100,UN,99.66,99.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOXYCYCLINE HYCLATE 50 MG CAP,2500010275,CDM,637,RC,,,,,,,,inpatient,facility,1,UN,9.17,9.17,0.73,9.17,,,,,,,,,,,,,,9.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.17,,,percent of total billed charges,,,,,,,,,9.17,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.5,,,percent of total billed charges,,,,,,,,,,,,,,,9.17,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,9.17,,,percent of total billed charges,,,4.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,9.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.4,,,percent of total billed charges,,
DOXYCYCLINE HYCLATE 50 MG CAP,2500010275,CDM,637,RC,,,,,,,,outpatient,facility,1,UN,9.17,9.17,0.73,548.68,,6.5,,,percent of total billed charges,,,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.17,,,percent of total billed charges,,,5.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.17,,,fee schedule,,,9.17,,,percent of total billed charges,,,,,,,,,9.17,,,percent of total billed charges,,,5.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.53,,,percent of total billed charges,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,4.77,,,percent of total billed charges,,,5.04,,,percent of total billed charges,,,,,,,,,5.41,,,percent of total billed charges,,,548.68,,,per diem,,,9.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.17,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.87,,,percent of total billed charges,,,9.17,,,percent of total billed charges,,,9.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,,7.42,,,percent of total billed charges,,,,,,,,,,,,,,,3.67,,,percent of total billed charges,,,,,,,,,3.39,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,9.17,,,percent of total billed charges,,,9.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.73,,,percent of total billed charges,,,9.17,,,percent of total billed charges,,,,,,,,,,,,,,,9.17,,,percent of total billed charges,,,9.17,,,percent of total billed charges,,,,,,,,,8.53,,,percent of total billed charges,,,,,,,,,,,,,,,8.53,,,percent of total billed charges,,,8.53,,,percent of total billed charges,,,8.53,,,percent of total billed charges,,,6.88,,,percent of total billed charges,,,9.17,,,percent of total billed charges,,,9.17,,,percent of total billed charges,,,9.17,,,percent of total billed charges,,,,,,,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.4,,,percent of total billed charges,,
DOXYCYCLINE HYCLATE 50 MG CAP,2500010275,CDM,637,RC,999,EAPG,,,,,,outpatient,facility,1,UN,9.17,9.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DRONABINOL 2.5 MG CAP,2500010280,CDM,636,RC,Q0167,HCPCS,904714461,NDC,,,,inpatient,facility,2.5,UN,15.58,15.58,1.25,15.58,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,,,,,,,15.58,,,percent of total billed charges,,,7.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.35,,,percent of total billed charges,,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,13.24,,,percent of total billed charges,,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,8.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.18,,,percent of total billed charges,,
DRONABINOL 2.5 MG CAP,2500010280,CDM,636,RC,Q0167,HCPCS,904714461,NDC,,,,outpatient,facility,2.5,UN,15.58,15.58,1.25,548.68,,11.05,,,percent of total billed charges,,,3.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,15.58,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.7,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,15.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,15.58,,,fee schedule,,,15.58,,,percent of total billed charges,,,,,,,,,15.58,,,percent of total billed charges,,,9.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,9.19,,,percent of total billed charges,,,548.68,,,per diem,,,15.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,15.58,,,percent of total billed charges,,,13.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.27,,,percent of total billed charges,,,15.58,,,percent of total billed charges,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.51,,,percent of total billed charges,,,12.61,,,percent of total billed charges,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15.58,,,percent of total billed charges,,,15.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.25,,,percent of total billed charges,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,15.58,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.79,,,fee schedule,,,15.58,,,percent of total billed charges,,,15.58,,,percent of total billed charges,,,15.58,,,percent of total billed charges,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.79,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.18,,,percent of total billed charges,,
DRONABINOL 2.5 MG CAP,2500010280,CDM,636,RC,Q0167,HCPCS,904714461,NDC,999,EAPG,,outpatient,facility,2.5,UN,15.58,15.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EFAVIRENZ 200 MG CAPSULE,2500010362,CDM,637,RC,6498040709,NDC,,,,,,inpatient,facility,200,UN,38.84,38.84,3.11,38.84,,,,,,,,,,,,,,38.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.84,,,percent of total billed charges,,,,,,,,,38.84,,,percent of total billed charges,,,19.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.3,,,percent of total billed charges,,,,,,,,,,,,,,,38.84,,,percent of total billed charges,,,33.01,,,percent of total billed charges,,,,,,,,,,,,,,,38.84,,,percent of total billed charges,,,20.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,38.84,,,percent of total billed charges,,,,,,,,,,,,,,,3.11,,,percent of total billed charges,,,38.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.88,,,percent of total billed charges,,
EFAVIRENZ 200 MG CAPSULE,2500010362,CDM,637,RC,6498040709,NDC,,,,,,outpatient,facility,200,UN,38.84,38.84,3.11,548.68,,27.54,,,percent of total billed charges,,,9.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,38.84,,,percent of total billed charges,,,24.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,27.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,27.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,38.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,14.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,38.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,38.84,,,fee schedule,,,38.84,,,percent of total billed charges,,,,,,,,,38.84,,,percent of total billed charges,,,23.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.67,,,percent of total billed charges,,,,,,,,,,,,,,,20.97,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,21.36,,,percent of total billed charges,,,,,,,,,22.92,,,percent of total billed charges,,,548.68,,,per diem,,,38.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,38.84,,,percent of total billed charges,,,33.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.63,,,percent of total billed charges,,,38.84,,,percent of total billed charges,,,38.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.2,,,percent of total billed charges,,,31.43,,,percent of total billed charges,,,,,,,,,,,,,,,15.54,,,percent of total billed charges,,,,,,,,,14.37,,,percent of total billed charges,,,14.37,,,percent of total billed charges,,,,,,,,,38.84,,,percent of total billed charges,,,38.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,38.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.11,,,percent of total billed charges,,,38.84,,,percent of total billed charges,,,,,,,,,,,,,,,38.84,,,percent of total billed charges,,,38.84,,,percent of total billed charges,,,,,,,,,36.13,,,percent of total billed charges,,,,,,,,,,,,,,,36.13,,,percent of total billed charges,,,36.13,,,percent of total billed charges,,,36.13,,,percent of total billed charges,,,29.13,,,percent of total billed charges,,,38.84,,,percent of total billed charges,,,38.84,,,percent of total billed charges,,,38.84,,,percent of total billed charges,,,,,,,,,27.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,22.88,,,percent of total billed charges,,
EFAVIRENZ 200 MG CAPSULE,2500010362,CDM,637,RC,6498040709,NDC,999,EAPG,,,,outpatient,facility,200,UN,38.84,38.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENALAPRILAT 1.25 MG/ML 1ML INJ,2500010436,CDM,250,RC,J3490,HCPCS,143978710,NDC,,,,inpatient,facility,1,UN,17.52,17.52,1.4,17.52,,,,,,,,,,,,,,17.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.52,,,percent of total billed charges,,,,,,,,,17.52,,,percent of total billed charges,,,8.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.51,,,percent of total billed charges,,,,,,,,,,,,,,,17.52,,,percent of total billed charges,,,14.89,,,percent of total billed charges,,,,,,,,,,,,,,,17.52,,,percent of total billed charges,,,9.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,17.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,17.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.32,,,percent of total billed charges,,
ENALAPRILAT 1.25 MG/ML 1ML INJ,2500010436,CDM,250,RC,J3490,HCPCS,143978710,NDC,,,,outpatient,facility,1,UN,17.52,17.52,1.2,548.68,,12.42,,,percent of total billed charges,,,4.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,17.52,,,percent of total billed charges,,,10.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,12.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,12.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,17.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.41,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,17.52,,,fee schedule,,,17.52,,,percent of total billed charges,,,,,,,,,17.52,,,percent of total billed charges,,,10.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.48,,,percent of total billed charges,,,,,,,,,,,,,,,17.52,,,percent of total billed charges,,,17.52,,,percent of total billed charges,,,17.52,,,percent of total billed charges,,,,,,,,,10.34,,,percent of total billed charges,,,548.68,,,per diem,,,17.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,17.52,,,percent of total billed charges,,,14.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.3,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.82,,,percent of total billed charges,,,14.18,,,percent of total billed charges,,,,,,,,,,,,,,,7.01,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17.52,,,percent of total billed charges,,,17.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.4,,,percent of total billed charges,,,17.52,,,percent of total billed charges,,,,,,,,,,,,,,,17.52,,,percent of total billed charges,,,17.52,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,13.14,,,percent of total billed charges,,,17.52,,,percent of total billed charges,,,17.52,,,percent of total billed charges,,,17.52,,,percent of total billed charges,,,,,,,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.32,,,percent of total billed charges,,
ENALAPRILAT 1.25 MG/ML 1ML INJ,2500010436,CDM,250,RC,J3490,HCPCS,143978710,NDC,435,EAPG,,outpatient,facility,1,UN,17.52,17.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENALAPRILAT 1.25 MG/ML 2ML INJ,2500010437,CDM,250,RC,J3490,HCPCS,143978610,NDC,,,,inpatient,facility,2,UN,31.28,31.28,2.5,31.28,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,31.28,,,percent of total billed charges,,,15.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.77,,,percent of total billed charges,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,26.59,,,percent of total billed charges,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,16.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.43,,,percent of total billed charges,,
ENALAPRILAT 1.25 MG/ML 2ML INJ,2500010437,CDM,250,RC,J3490,HCPCS,143978610,NDC,,,,outpatient,facility,2,UN,31.28,31.28,1.2,548.68,,22.18,,,percent of total billed charges,,,7.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,31.28,,,percent of total billed charges,,,19.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,21.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,21.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.45,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,31.28,,,fee schedule,,,31.28,,,percent of total billed charges,,,,,,,,,31.28,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.29,,,percent of total billed charges,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,18.46,,,percent of total billed charges,,,548.68,,,per diem,,,31.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,31.28,,,percent of total billed charges,,,26.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.61,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.1,,,percent of total billed charges,,,25.31,,,percent of total billed charges,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,31.28,,,percent of total billed charges,,,31.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.5,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,23.46,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,31.28,,,percent of total billed charges,,,,,,,,,21.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.43,,,percent of total billed charges,,
ENALAPRILAT 1.25 MG/ML 2ML INJ,2500010437,CDM,250,RC,J3490,HCPCS,143978610,NDC,435,EAPG,,outpatient,facility,2,UN,31.28,31.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ENTACAPONE 200 MG TAB,2500010450,CDM,637,RC,6586265401,NDC,,,,,,inpatient,facility,200,UN,14.98,14.98,1.2,14.98,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,14.98,,,percent of total billed charges,,,7.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.99,,,percent of total billed charges,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,12.73,,,percent of total billed charges,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,7.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.83,,,percent of total billed charges,,
ENTACAPONE 200 MG TAB,2500010450,CDM,637,RC,6586265401,NDC,,,,,,outpatient,facility,200,UN,14.98,14.98,1.2,548.68,,10.62,,,percent of total billed charges,,,3.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.98,,,percent of total billed charges,,,9.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.48,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.98,,,fee schedule,,,14.98,,,percent of total billed charges,,,,,,,,,14.98,,,percent of total billed charges,,,9.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.67,,,percent of total billed charges,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,8.24,,,percent of total billed charges,,,,,,,,,8.84,,,percent of total billed charges,,,548.68,,,per diem,,,14.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.98,,,percent of total billed charges,,,12.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.96,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.11,,,percent of total billed charges,,,12.12,,,percent of total billed charges,,,,,,,,,,,,,,,5.99,,,percent of total billed charges,,,,,,,,,5.54,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,,,,,,,14.98,,,percent of total billed charges,,,14.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.2,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,13.93,,,percent of total billed charges,,,,,,,,,,,,,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,13.93,,,percent of total billed charges,,,11.23,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,10.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.83,,,percent of total billed charges,,
ENTACAPONE 200 MG TAB,2500010450,CDM,637,RC,6586265401,NDC,999,EAPG,,,,outpatient,facility,200,UN,14.98,14.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPHEDRINE 50 MG/ML AMP,2500010460,CDM,250,RC,4202321625,NDC,,,,,,inpatient,facility,1,UN,95.83,95.83,7.67,95.83,,,,,,,,,,,,,,95.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.83,,,percent of total billed charges,,,,,,,,,95.83,,,percent of total billed charges,,,48.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.5,,,percent of total billed charges,,,,,,,,,,,,,,,95.83,,,percent of total billed charges,,,81.46,,,percent of total billed charges,,,,,,,,,,,,,,,95.83,,,percent of total billed charges,,,50.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,95.83,,,percent of total billed charges,,,,,,,,,,,,,,,7.67,,,percent of total billed charges,,,95.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.46,,,percent of total billed charges,,
EPHEDRINE 50 MG/ML AMP,2500010460,CDM,250,RC,4202321625,NDC,,,,,,outpatient,facility,1,UN,95.83,95.83,7.67,548.68,,67.95,,,percent of total billed charges,,,23.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,95.83,,,percent of total billed charges,,,60.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,67.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,67.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,95.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,35.07,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,95.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,95.83,,,fee schedule,,,95.83,,,percent of total billed charges,,,,,,,,,95.83,,,percent of total billed charges,,,58.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,56.54,,,percent of total billed charges,,,548.68,,,per diem,,,95.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,95.83,,,percent of total billed charges,,,81.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.9,,,percent of total billed charges,,,95.83,,,percent of total billed charges,,,95.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.65,,,percent of total billed charges,,,77.55,,,percent of total billed charges,,,,,,,,,,,,,,,38.33,,,percent of total billed charges,,,,,,,,,38.33,,,percent of total billed charges,,,38.33,,,percent of total billed charges,,,,,,,,,95.83,,,percent of total billed charges,,,95.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,95.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.67,,,percent of total billed charges,,,95.83,,,percent of total billed charges,,,,,,,,,,,,,,,95.83,,,percent of total billed charges,,,95.83,,,percent of total billed charges,,,,,,,,,38.33,,,percent of total billed charges,,,,,,,,,,,,,,,38.33,,,percent of total billed charges,,,38.33,,,percent of total billed charges,,,38.33,,,percent of total billed charges,,,71.87,,,percent of total billed charges,,,95.83,,,percent of total billed charges,,,95.83,,,percent of total billed charges,,,95.83,,,percent of total billed charges,,,,,,,,,67.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,56.46,,,percent of total billed charges,,
EPHEDRINE 50 MG/ML AMP,2500010460,CDM,250,RC,4202321625,NDC,999,EAPG,,,,outpatient,facility,1,UN,95.83,95.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ERGOCALCIFEROL 50000 IU CAP,2500010530,CDM,637,RC,6438073706,NDC,,,,,,inpatient,facility,50000,UN,6.5,6.5,0.52,6.5,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,,,,,,,6.5,,,percent of total billed charges,,,3.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,5.52,,,percent of total billed charges,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,3.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,
ERGOCALCIFEROL 50000 IU CAP,2500010530,CDM,637,RC,6438073706,NDC,,,,,,outpatient,facility,50000,UN,6.5,6.5,0.52,548.68,,4.61,,,percent of total billed charges,,,1.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.5,,,percent of total billed charges,,,4.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.38,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.5,,,fee schedule,,,6.5,,,percent of total billed charges,,,,,,,,,6.5,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,3.38,,,percent of total billed charges,,,3.58,,,percent of total billed charges,,,,,,,,,3.84,,,percent of total billed charges,,,548.68,,,per diem,,,6.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.5,,,percent of total billed charges,,,5.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.45,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.38,,,percent of total billed charges,,,5.26,,,percent of total billed charges,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,,,,,,,,2.4,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,,,,,,,6.5,,,percent of total billed charges,,,6.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.52,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,,,,,,,6.05,,,percent of total billed charges,,,,,,,,,,,,,,,6.05,,,percent of total billed charges,,,6.05,,,percent of total billed charges,,,6.05,,,percent of total billed charges,,,4.88,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,6.5,,,percent of total billed charges,,,,,,,,,4.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.83,,,percent of total billed charges,,
ERGOCALCIFEROL 50000 IU CAP,2500010530,CDM,637,RC,6438073706,NDC,999,EAPG,,,,outpatient,facility,50000,UN,6.5,6.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ERYTHROMYCIN 250 MG TABEC,2500010573,CDM,637,RC,5253618003,NDC,,,,,,inpatient,facility,250,UN,27.68,27.68,2.21,27.68,,,,,,,,,,,,,,27.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.68,,,percent of total billed charges,,,,,,,,,27.68,,,percent of total billed charges,,,14.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.61,,,percent of total billed charges,,,,,,,,,,,,,,,27.68,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,27.68,,,percent of total billed charges,,,14.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,27.68,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,27.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.31,,,percent of total billed charges,,
ERYTHROMYCIN 250 MG TABEC,2500010573,CDM,637,RC,5253618003,NDC,,,,,,outpatient,facility,250,UN,27.68,27.68,2.21,548.68,,19.63,,,percent of total billed charges,,,6.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,27.68,,,percent of total billed charges,,,17.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,19.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,19.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,27.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.13,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,27.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,27.68,,,fee schedule,,,27.68,,,percent of total billed charges,,,,,,,,,27.68,,,percent of total billed charges,,,16.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.72,,,percent of total billed charges,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,14.39,,,percent of total billed charges,,,15.22,,,percent of total billed charges,,,,,,,,,16.33,,,percent of total billed charges,,,548.68,,,per diem,,,27.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,27.68,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.7,,,percent of total billed charges,,,27.68,,,percent of total billed charges,,,27.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.67,,,percent of total billed charges,,,22.4,,,percent of total billed charges,,,,,,,,,,,,,,,11.07,,,percent of total billed charges,,,,,,,,,10.24,,,percent of total billed charges,,,10.24,,,percent of total billed charges,,,,,,,,,27.68,,,percent of total billed charges,,,27.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.21,,,percent of total billed charges,,,27.68,,,percent of total billed charges,,,,,,,,,,,,,,,27.68,,,percent of total billed charges,,,27.68,,,percent of total billed charges,,,,,,,,,25.75,,,percent of total billed charges,,,,,,,,,,,,,,,25.75,,,percent of total billed charges,,,25.75,,,percent of total billed charges,,,25.75,,,percent of total billed charges,,,20.76,,,percent of total billed charges,,,27.68,,,percent of total billed charges,,,27.68,,,percent of total billed charges,,,27.68,,,percent of total billed charges,,,,,,,,,19.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,16.31,,,percent of total billed charges,,
ERYTHROMYCIN 250 MG TABEC,2500010573,CDM,637,RC,5253618003,NDC,999,EAPG,,,,outpatient,facility,250,UN,27.68,27.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ERYTHROMYCIN 200 MG/5 ML,2500010592,CDM,637,RC,6255963001,NDC,,,,,,inpatient,facility,5,UN,14.92,14.92,1.19,14.92,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,,,,,,,14.92,,,percent of total billed charges,,,7.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.95,,,percent of total billed charges,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,12.68,,,percent of total billed charges,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,14.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.79,,,percent of total billed charges,,
ERYTHROMYCIN 200 MG/5 ML,2500010592,CDM,637,RC,6255963001,NDC,,,,,,outpatient,facility,5,UN,14.92,14.92,1.19,548.68,,10.58,,,percent of total billed charges,,,3.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.92,,,percent of total billed charges,,,9.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.92,,,fee schedule,,,14.92,,,percent of total billed charges,,,,,,,,,14.92,,,percent of total billed charges,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,8.06,,,percent of total billed charges,,,7.76,,,percent of total billed charges,,,8.21,,,percent of total billed charges,,,,,,,,,8.8,,,percent of total billed charges,,,548.68,,,per diem,,,14.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.92,,,percent of total billed charges,,,12.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,14.92,,,percent of total billed charges,,,14.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.07,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,5.52,,,percent of total billed charges,,,5.52,,,percent of total billed charges,,,,,,,,,14.92,,,percent of total billed charges,,,14.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.19,,,percent of total billed charges,,,14.92,,,percent of total billed charges,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,14.92,,,percent of total billed charges,,,,,,,,,13.88,,,percent of total billed charges,,,,,,,,,,,,,,,13.88,,,percent of total billed charges,,,13.88,,,percent of total billed charges,,,13.88,,,percent of total billed charges,,,11.19,,,percent of total billed charges,,,14.92,,,percent of total billed charges,,,14.92,,,percent of total billed charges,,,14.92,,,percent of total billed charges,,,,,,,,,10.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.79,,,percent of total billed charges,,
ERYTHROMYCIN 200 MG/5 ML,2500010592,CDM,637,RC,6255963001,NDC,999,EAPG,,,,outpatient,facility,5,UN,14.92,14.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ERYTHROMYCIN OPH OINT 1 GM PKT,2500010602,CDM,637,RC,574402450,NDC,,,,,,inpatient,facility,1,UN,23.93,23.93,1.91,23.93,,,,,,,,,,,,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.93,,,percent of total billed charges,,,,,,,,,23.93,,,percent of total billed charges,,,12.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.36,,,percent of total billed charges,,,,,,,,,,,,,,,23.93,,,percent of total billed charges,,,20.34,,,percent of total billed charges,,,,,,,,,,,,,,,23.93,,,percent of total billed charges,,,12.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.1,,,percent of total billed charges,,
ERYTHROMYCIN OPH OINT 1 GM PKT,2500010602,CDM,637,RC,574402450,NDC,,,,,,outpatient,facility,1,UN,23.93,23.93,1.91,548.68,,16.97,,,percent of total billed charges,,,5.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,23.93,,,percent of total billed charges,,,15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,16.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,16.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.76,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,23.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,23.93,,,fee schedule,,,23.93,,,percent of total billed charges,,,,,,,,,23.93,,,percent of total billed charges,,,14.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.05,,,percent of total billed charges,,,,,,,,,,,,,,,12.92,,,percent of total billed charges,,,12.44,,,percent of total billed charges,,,13.16,,,percent of total billed charges,,,,,,,,,14.12,,,percent of total billed charges,,,548.68,,,per diem,,,23.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,23.93,,,percent of total billed charges,,,20.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.71,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.14,,,percent of total billed charges,,,19.36,,,percent of total billed charges,,,,,,,,,,,,,,,9.57,,,percent of total billed charges,,,,,,,,,8.85,,,percent of total billed charges,,,8.85,,,percent of total billed charges,,,,,,,,,23.93,,,percent of total billed charges,,,23.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.91,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,,,,,,,,,,,,,23.93,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,,,,,,,22.26,,,percent of total billed charges,,,,,,,,,,,,,,,22.26,,,percent of total billed charges,,,22.26,,,percent of total billed charges,,,22.26,,,percent of total billed charges,,,17.95,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,23.93,,,percent of total billed charges,,,,,,,,,16.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.1,,,percent of total billed charges,,
ERYTHROMYCIN OPH OINT 1 GM PKT,2500010602,CDM,637,RC,574402450,NDC,999,EAPG,,,,outpatient,facility,1,UN,23.93,23.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESMOLOL HCL 10 MG/ML 10 ML INJ,2500010640,CDM,250,RC,J3490,HCPCS,5515019410,NDC,,,,inpatient,facility,10,ML,29.04,29.04,2.32,29.04,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,,,,,,,29.04,,,percent of total billed charges,,,14.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.42,,,percent of total billed charges,,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,15.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,29.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.11,,,percent of total billed charges,,
ESMOLOL HCL 10 MG/ML 10 ML INJ,2500010640,CDM,250,RC,J3490,HCPCS,5515019410,NDC,,,,outpatient,facility,10,ML,29.04,29.04,1.2,548.68,,20.59,,,percent of total billed charges,,,7.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,29.04,,,percent of total billed charges,,,18.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,20.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,20.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,29.04,,,fee schedule,,,29.04,,,percent of total billed charges,,,,,,,,,29.04,,,percent of total billed charges,,,17.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,29.04,,,percent of total billed charges,,,29.04,,,percent of total billed charges,,,,,,,,,17.13,,,percent of total billed charges,,,548.68,,,per diem,,,29.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,29.04,,,percent of total billed charges,,,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.42,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.59,,,percent of total billed charges,,,23.5,,,percent of total billed charges,,,,,,,,,,,,,,,11.62,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,29.04,,,percent of total billed charges,,,29.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.32,,,percent of total billed charges,,,29.04,,,percent of total billed charges,,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,29.04,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,21.78,,,percent of total billed charges,,,29.04,,,percent of total billed charges,,,29.04,,,percent of total billed charges,,,29.04,,,percent of total billed charges,,,,,,,,,20.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.11,,,percent of total billed charges,,
ESMOLOL HCL 10 MG/ML 10 ML INJ,2500010640,CDM,250,RC,J3490,HCPCS,5515019410,NDC,435,EAPG,,outpatient,facility,10,ML,29.04,29.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESTRADIOL 0.1 MG/24 HR 3D PTCH,2500010663,CDM,637,RC,781710454,NDC,,,,,,inpatient,facility,1,UN,76.59,76.59,6.13,76.59,,,,,,,,,,,,,,76.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.59,,,percent of total billed charges,,,,,,,,,76.59,,,percent of total billed charges,,,39.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.95,,,percent of total billed charges,,,,,,,,,,,,,,,76.59,,,percent of total billed charges,,,65.1,,,percent of total billed charges,,,,,,,,,,,,,,,76.59,,,percent of total billed charges,,,40.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,76.59,,,percent of total billed charges,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,76.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,76.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.13,,,percent of total billed charges,,
ESTRADIOL 0.1 MG/24 HR 3D PTCH,2500010663,CDM,637,RC,781710454,NDC,,,,,,outpatient,facility,1,UN,76.59,76.59,6.13,548.68,,54.31,,,percent of total billed charges,,,18.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,76.59,,,percent of total billed charges,,,48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,53.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,53.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,76.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,28.03,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,76.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,76.59,,,fee schedule,,,76.59,,,percent of total billed charges,,,,,,,,,76.59,,,percent of total billed charges,,,46.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.57,,,percent of total billed charges,,,,,,,,,,,,,,,41.36,,,percent of total billed charges,,,39.83,,,percent of total billed charges,,,42.12,,,percent of total billed charges,,,,,,,,,45.19,,,percent of total billed charges,,,548.68,,,per diem,,,76.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,76.59,,,percent of total billed charges,,,65.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.68,,,percent of total billed charges,,,76.59,,,percent of total billed charges,,,76.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.67,,,percent of total billed charges,,,61.98,,,percent of total billed charges,,,,,,,,,,,,,,,30.64,,,percent of total billed charges,,,,,,,,,28.34,,,percent of total billed charges,,,28.34,,,percent of total billed charges,,,,,,,,,76.59,,,percent of total billed charges,,,76.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,76.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.13,,,percent of total billed charges,,,76.59,,,percent of total billed charges,,,,,,,,,,,,,,,76.59,,,percent of total billed charges,,,76.59,,,percent of total billed charges,,,,,,,,,71.24,,,percent of total billed charges,,,,,,,,,,,,,,,71.24,,,percent of total billed charges,,,71.24,,,percent of total billed charges,,,71.24,,,percent of total billed charges,,,57.44,,,percent of total billed charges,,,76.59,,,percent of total billed charges,,,76.59,,,percent of total billed charges,,,76.59,,,percent of total billed charges,,,,,,,,,53.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,45.13,,,percent of total billed charges,,
ESTRADIOL 0.1 MG/24 HR 3D PTCH,2500010663,CDM,637,RC,781710454,NDC,999,EAPG,,,,outpatient,facility,1,UN,76.59,76.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESTRADIOL 1 MG TAB,2500010667,CDM,637,RC,555088602,NDC,,,,,,inpatient,facility,1,UN,2.24,2.24,0.18,2.24,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,
ESTRADIOL 1 MG TAB,2500010667,CDM,637,RC,555088602,NDC,,,,,,outpatient,facility,1,UN,2.24,2.24,0.18,548.68,,1.59,,,percent of total billed charges,,,0.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.24,,,percent of total billed charges,,,1.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.82,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.24,,,fee schedule,,,2.24,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,548.68,,,per diem,,,2.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.24,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.32,,,percent of total billed charges,,
ESTRADIOL 1 MG TAB,2500010667,CDM,637,RC,555088602,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.24,2.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESTRADIOL CREAM 42.5 GM,2500010669,CDM,637,RC,4778110444,NDC,,,,,,inpatient,facility,42.5,UN,1120.94,1120.94,89.68,1120.94,,,,,,,,,,,,,,1120.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1120.94,,,percent of total billed charges,,,,,,,,,1120.94,,,percent of total billed charges,,,572.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,954.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,672.56,,,percent of total billed charges,,,,,,,,,,,,,,,1120.94,,,percent of total billed charges,,,952.8,,,percent of total billed charges,,,,,,,,,,,,,,,1120.94,,,percent of total billed charges,,,595.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,448.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1120.94,,,percent of total billed charges,,,,,,,,,,,,,,,89.68,,,percent of total billed charges,,,1120.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1120.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,660.46,,,percent of total billed charges,,
ESTRADIOL CREAM 42.5 GM,2500010669,CDM,637,RC,4778110444,NDC,,,,,,outpatient,facility,42.5,UN,1120.94,1120.94,89.68,1120.94,,794.86,,,percent of total billed charges,,,273.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1120.94,,,percent of total billed charges,,,702.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,788.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,788.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1120.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,410.26,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1120.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1120.94,,,fee schedule,,,1120.94,,,percent of total billed charges,,,,,,,,,1120.94,,,percent of total billed charges,,,687.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,798.67,,,percent of total billed charges,,,,,,,,,,,,,,,605.31,,,percent of total billed charges,,,582.89,,,percent of total billed charges,,,616.52,,,percent of total billed charges,,,,,,,,,661.35,,,percent of total billed charges,,,548.68,,,per diem,,,1120.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1120.94,,,percent of total billed charges,,,952.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,595.33,,,percent of total billed charges,,,1120.94,,,percent of total billed charges,,,1120.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,756.19,,,percent of total billed charges,,,907.06,,,percent of total billed charges,,,,,,,,,,,,,,,448.38,,,percent of total billed charges,,,,,,,,,414.75,,,percent of total billed charges,,,414.75,,,percent of total billed charges,,,,,,,,,1120.94,,,percent of total billed charges,,,1120.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1120.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,89.68,,,percent of total billed charges,,,1120.94,,,percent of total billed charges,,,,,,,,,,,,,,,1120.94,,,percent of total billed charges,,,1120.94,,,percent of total billed charges,,,,,,,,,1042.7,,,percent of total billed charges,,,,,,,,,,,,,,,1042.7,,,percent of total billed charges,,,1042.7,,,percent of total billed charges,,,1042.7,,,percent of total billed charges,,,840.71,,,percent of total billed charges,,,1120.94,,,percent of total billed charges,,,1120.94,,,percent of total billed charges,,,1120.94,,,percent of total billed charges,,,,,,,,,785.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,560.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,660.46,,,percent of total billed charges,,
ESTRADIOL CREAM 42.5 GM,2500010669,CDM,637,RC,4778110444,NDC,999,EAPG,,,,outpatient,facility,42.5,UN,1120.94,1120.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESTROGEN CONJ 0.3 MG TAB,2500010710,CDM,637,RC,46110081,NDC,,,,,,inpatient,facility,0.3,UN,22.11,22.11,1.77,22.11,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,22.11,,,percent of total billed charges,,,11.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,18.79,,,percent of total billed charges,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.03,,,percent of total billed charges,,
ESTROGEN CONJ 0.3 MG TAB,2500010710,CDM,637,RC,46110081,NDC,,,,,,outpatient,facility,0.3,UN,22.11,22.11,1.77,548.68,,15.68,,,percent of total billed charges,,,5.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,22.11,,,percent of total billed charges,,,13.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,15.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,15.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.09,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,22.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,22.11,,,fee schedule,,,22.11,,,percent of total billed charges,,,,,,,,,22.11,,,percent of total billed charges,,,13.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.75,,,percent of total billed charges,,,,,,,,,,,,,,,11.94,,,percent of total billed charges,,,11.5,,,percent of total billed charges,,,12.16,,,percent of total billed charges,,,,,,,,,13.04,,,percent of total billed charges,,,548.68,,,per diem,,,22.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,22.11,,,percent of total billed charges,,,18.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,17.89,,,percent of total billed charges,,,,,,,,,,,,,,,8.84,,,percent of total billed charges,,,,,,,,,8.18,,,percent of total billed charges,,,8.18,,,percent of total billed charges,,,,,,,,,22.11,,,percent of total billed charges,,,22.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.77,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,20.57,,,percent of total billed charges,,,,,,,,,,,,,,,20.57,,,percent of total billed charges,,,20.57,,,percent of total billed charges,,,20.57,,,percent of total billed charges,,,16.58,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,15.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.03,,,percent of total billed charges,,
ESTROGEN CONJ 0.3 MG TAB,2500010710,CDM,637,RC,46110081,NDC,999,EAPG,,,,outpatient,facility,0.3,UN,22.11,22.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESTROGEN CONJ 0.625 MG TAB,2500010711,CDM,637,RC,46110281,NDC,,,,,,inpatient,facility,0.625,UN,22.8,22.8,1.82,22.8,,,,,,,,,,,,,,22.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.8,,,percent of total billed charges,,,,,,,,,22.8,,,percent of total billed charges,,,11.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.68,,,percent of total billed charges,,,,,,,,,,,,,,,22.8,,,percent of total billed charges,,,19.38,,,percent of total billed charges,,,,,,,,,,,,,,,22.8,,,percent of total billed charges,,,12.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,22.8,,,percent of total billed charges,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.43,,,percent of total billed charges,,
ESTROGEN CONJ 0.625 MG TAB,2500010711,CDM,637,RC,46110281,NDC,,,,,,outpatient,facility,0.625,UN,22.8,22.8,1.82,548.68,,16.17,,,percent of total billed charges,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,22.8,,,percent of total billed charges,,,14.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,16.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,16.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,22.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.34,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,22.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,22.8,,,fee schedule,,,22.8,,,percent of total billed charges,,,,,,,,,22.8,,,percent of total billed charges,,,13.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.25,,,percent of total billed charges,,,,,,,,,,,,,,,12.31,,,percent of total billed charges,,,11.86,,,percent of total billed charges,,,12.54,,,percent of total billed charges,,,,,,,,,13.45,,,percent of total billed charges,,,548.68,,,per diem,,,22.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,22.8,,,percent of total billed charges,,,19.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.11,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.38,,,percent of total billed charges,,,18.45,,,percent of total billed charges,,,,,,,,,,,,,,,9.12,,,percent of total billed charges,,,,,,,,,8.44,,,percent of total billed charges,,,8.44,,,percent of total billed charges,,,,,,,,,22.8,,,percent of total billed charges,,,22.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.82,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,,,,,,,,,,,,,22.8,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,,,,,,,21.21,,,percent of total billed charges,,,,,,,,,,,,,,,21.21,,,percent of total billed charges,,,21.21,,,percent of total billed charges,,,21.21,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,,,,,,,15.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.43,,,percent of total billed charges,,
ESTROGEN CONJ 0.625 MG TAB,2500010711,CDM,637,RC,46110281,NDC,999,EAPG,,,,outpatient,facility,0.625,UN,22.8,22.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ETHAMBUTOL HCL 100 MG TAB,2500010750,CDM,637,RC,6818028001,NDC,,,,,,inpatient,facility,100,UN,1.94,1.94,0.16,1.94,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,
ETHAMBUTOL HCL 100 MG TAB,2500010750,CDM,637,RC,6818028001,NDC,,,,,,outpatient,facility,100,UN,1.94,1.94,0.16,548.68,,1.38,,,percent of total billed charges,,,0.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.94,,,percent of total billed charges,,,1.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.94,,,fee schedule,,,1.94,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,1.14,,,percent of total billed charges,,,548.68,,,per diem,,,1.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.94,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,0.72,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.14,,,percent of total billed charges,,
ETHAMBUTOL HCL 100 MG TAB,2500010750,CDM,637,RC,6818028001,NDC,999,EAPG,,,,outpatient,facility,100,UN,1.94,1.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ETHAMBUTOL HCL 400 MG TAB,2500010754,CDM,637,RC,6885001202,NDC,,,,,,inpatient,facility,400,UN,2.57,2.57,0.21,2.57,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,2.57,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,
ETHAMBUTOL HCL 400 MG TAB,2500010754,CDM,637,RC,6885001202,NDC,,,,,,outpatient,facility,400,UN,2.57,2.57,0.21,548.68,,1.82,,,percent of total billed charges,,,0.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.57,,,percent of total billed charges,,,1.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.94,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.57,,,fee schedule,,,2.57,,,percent of total billed charges,,,,,,,,,2.57,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,548.68,,,per diem,,,2.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.57,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,2.57,,,percent of total billed charges,,,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.51,,,percent of total billed charges,,
ETHAMBUTOL HCL 400 MG TAB,2500010754,CDM,637,RC,6885001202,NDC,999,EAPG,,,,outpatient,facility,400,UN,2.57,2.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ETOMIDATE 2 MG/ML 10 ML AMP,2500010860,CDM,250,RC,J3490,HCPCS,5515022110,NDC,,,,inpatient,facility,10,UN,31.68,31.68,2.53,31.68,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,,,,,,,31.68,,,percent of total billed charges,,,16.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.01,,,percent of total billed charges,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,26.93,,,percent of total billed charges,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,16.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.67,,,percent of total billed charges,,
ETOMIDATE 2 MG/ML 10 ML AMP,2500010860,CDM,250,RC,J3490,HCPCS,5515022110,NDC,,,,outpatient,facility,10,UN,31.68,31.68,1.2,548.68,,22.46,,,percent of total billed charges,,,7.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,31.68,,,percent of total billed charges,,,19.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,22.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,22.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.59,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,31.68,,,fee schedule,,,31.68,,,percent of total billed charges,,,,,,,,,31.68,,,percent of total billed charges,,,19.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.57,,,percent of total billed charges,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,,,,,,,18.69,,,percent of total billed charges,,,548.68,,,per diem,,,31.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,31.68,,,percent of total billed charges,,,26.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.83,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.37,,,percent of total billed charges,,,25.64,,,percent of total billed charges,,,,,,,,,,,,,,,12.67,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,31.68,,,percent of total billed charges,,,31.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.53,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,23.76,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,,,,,,,22.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.67,,,percent of total billed charges,,
ETOMIDATE 2 MG/ML 10 ML AMP,2500010860,CDM,250,RC,J3490,HCPCS,5515022110,NDC,435,EAPG,,outpatient,facility,10,UN,31.68,31.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ETOMIDATE 40 MG/20 ML INJ,2500010863,CDM,250,RC,J3490,HCPCS,5515022220,NDC,,,,inpatient,facility,20,UN,36.63,36.63,2.93,36.63,,,,,,,,,,,,,,36.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.63,,,percent of total billed charges,,,,,,,,,36.63,,,percent of total billed charges,,,18.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.98,,,percent of total billed charges,,,,,,,,,,,,,,,36.63,,,percent of total billed charges,,,31.14,,,percent of total billed charges,,,,,,,,,,,,,,,36.63,,,percent of total billed charges,,,19.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,36.63,,,percent of total billed charges,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,36.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.58,,,percent of total billed charges,,
ETOMIDATE 40 MG/20 ML INJ,2500010863,CDM,250,RC,J3490,HCPCS,5515022220,NDC,,,,outpatient,facility,20,UN,36.63,36.63,1.2,548.68,,25.97,,,percent of total billed charges,,,8.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,36.63,,,percent of total billed charges,,,22.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,25.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,25.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,36.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,13.41,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,36.63,,,fee schedule,,,36.63,,,percent of total billed charges,,,,,,,,,36.63,,,percent of total billed charges,,,22.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.1,,,percent of total billed charges,,,,,,,,,,,,,,,36.63,,,percent of total billed charges,,,36.63,,,percent of total billed charges,,,36.63,,,percent of total billed charges,,,,,,,,,21.61,,,percent of total billed charges,,,548.68,,,per diem,,,36.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,36.63,,,percent of total billed charges,,,31.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.45,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.71,,,percent of total billed charges,,,29.64,,,percent of total billed charges,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,36.63,,,percent of total billed charges,,,36.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,36.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.93,,,percent of total billed charges,,,36.63,,,percent of total billed charges,,,,,,,,,,,,,,,36.63,,,percent of total billed charges,,,36.63,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,27.47,,,percent of total billed charges,,,36.63,,,percent of total billed charges,,,36.63,,,percent of total billed charges,,,36.63,,,percent of total billed charges,,,,,,,,,25.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,21.58,,,percent of total billed charges,,
ETOMIDATE 40 MG/20 ML INJ,2500010863,CDM,250,RC,J3490,HCPCS,5515022220,NDC,435,EAPG,,outpatient,facility,20,UN,36.63,36.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FAMCICLOVIR 500 MG TAB,2500010895,CDM,637,RC,3334202607,NDC,,,,,,inpatient,facility,500,UN,41.87,41.87,3.35,41.87,,,,,,,,,,,,,,41.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.87,,,percent of total billed charges,,,,,,,,,41.87,,,percent of total billed charges,,,21.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.12,,,percent of total billed charges,,,,,,,,,,,,,,,41.87,,,percent of total billed charges,,,35.59,,,percent of total billed charges,,,,,,,,,,,,,,,41.87,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,41.87,,,percent of total billed charges,,,,,,,,,,,,,,,3.35,,,percent of total billed charges,,,41.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.67,,,percent of total billed charges,,
FAMCICLOVIR 500 MG TAB,2500010895,CDM,637,RC,3334202607,NDC,,,,,,outpatient,facility,500,UN,41.87,41.87,3.35,548.68,,29.69,,,percent of total billed charges,,,10.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,41.87,,,percent of total billed charges,,,26.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,29.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,29.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,41.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,15.32,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,41.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,41.87,,,fee schedule,,,41.87,,,percent of total billed charges,,,,,,,,,41.87,,,percent of total billed charges,,,25.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.83,,,percent of total billed charges,,,,,,,,,,,,,,,22.61,,,percent of total billed charges,,,21.77,,,percent of total billed charges,,,23.03,,,percent of total billed charges,,,,,,,,,24.7,,,percent of total billed charges,,,548.68,,,per diem,,,41.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,41.87,,,percent of total billed charges,,,35.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.24,,,percent of total billed charges,,,41.87,,,percent of total billed charges,,,41.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,33.88,,,percent of total billed charges,,,,,,,,,,,,,,,16.75,,,percent of total billed charges,,,,,,,,,15.49,,,percent of total billed charges,,,15.49,,,percent of total billed charges,,,,,,,,,41.87,,,percent of total billed charges,,,41.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,41.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.35,,,percent of total billed charges,,,41.87,,,percent of total billed charges,,,,,,,,,,,,,,,41.87,,,percent of total billed charges,,,41.87,,,percent of total billed charges,,,,,,,,,38.95,,,percent of total billed charges,,,,,,,,,,,,,,,38.95,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,31.4,,,percent of total billed charges,,,41.87,,,percent of total billed charges,,,41.87,,,percent of total billed charges,,,41.87,,,percent of total billed charges,,,,,,,,,29.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,24.67,,,percent of total billed charges,,
FAMCICLOVIR 500 MG TAB,2500010895,CDM,637,RC,3334202607,NDC,999,EAPG,,,,outpatient,facility,500,UN,41.87,41.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FAMOTIDINE 20 MG TAB,2500010900,CDM,637,RC,172572860,NDC,,,,,,inpatient,facility,20,UN,7.98,7.98,0.64,7.98,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,,,,,,,7.98,,,percent of total billed charges,,,4.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,6.78,,,percent of total billed charges,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,4.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.7,,,percent of total billed charges,,
FAMOTIDINE 20 MG TAB,2500010900,CDM,637,RC,172572860,NDC,,,,,,outpatient,facility,20,UN,7.98,7.98,0.64,548.68,,5.66,,,percent of total billed charges,,,1.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.98,,,percent of total billed charges,,,5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.92,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.98,,,fee schedule,,,7.98,,,percent of total billed charges,,,,,,,,,7.98,,,percent of total billed charges,,,4.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.69,,,percent of total billed charges,,,,,,,,,,,,,,,4.31,,,percent of total billed charges,,,4.15,,,percent of total billed charges,,,4.39,,,percent of total billed charges,,,,,,,,,4.71,,,percent of total billed charges,,,548.68,,,per diem,,,7.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.98,,,percent of total billed charges,,,6.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.24,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.38,,,percent of total billed charges,,,6.46,,,percent of total billed charges,,,,,,,,,,,,,,,3.19,,,percent of total billed charges,,,,,,,,,2.95,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,,,,,,,7.98,,,percent of total billed charges,,,7.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.64,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,,,,,,,,,,,,,7.98,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,,,,,,,7.42,,,percent of total billed charges,,,,,,,,,,,,,,,7.42,,,percent of total billed charges,,,7.42,,,percent of total billed charges,,,7.42,,,percent of total billed charges,,,5.99,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,7.98,,,percent of total billed charges,,,,,,,,,5.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.7,,,percent of total billed charges,,
FAMOTIDINE 20 MG TAB,2500010900,CDM,637,RC,172572860,NDC,999,EAPG,,,,outpatient,facility,20,UN,7.98,7.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FAT EMULSION IV 20  250 ML,2500010912,CDM,250,RC,B4185,HCPCS,6332382074,NDC,,,,inpatient,facility,250,UN,85.8,85.8,6.86,85.8,,,,,,,,,,,,,,85.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.8,,,percent of total billed charges,,,,,,,,,85.8,,,percent of total billed charges,,,43.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,,85.8,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,,,,,,,,,,,,,85.8,,,percent of total billed charges,,,45.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,85.8,,,percent of total billed charges,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,85.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.55,,,percent of total billed charges,,
FAT EMULSION IV 20  250 ML,2500010912,CDM,250,RC,B4185,HCPCS,6332382074,NDC,,,,outpatient,facility,250,UN,85.8,85.8,5.83,548.68,,60.84,,,percent of total billed charges,,,20.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,85.8,,,percent of total billed charges,,,6.17,,,fee schedule,,,5.83,,,fee schedule,,,,,,,,,5.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,85.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,31.4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,85.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,16.29,,,fee schedule,,,85.8,,,percent of total billed charges,,,,,,,,,85.8,,,percent of total billed charges,,,52.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,50.62,,,percent of total billed charges,,,548.68,,,per diem,,,85.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,85.8,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,45.57,,,percent of total billed charges,,,85.8,,,percent of total billed charges,,,85.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.88,,,percent of total billed charges,,,69.43,,,percent of total billed charges,,,,,,,,,,,,,,,34.32,,,percent of total billed charges,,,,,,,,,37.42,,,fee schedule,,,26.93,,,fee schedule,,,,,,,,,85.8,,,percent of total billed charges,,,85.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,85.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.86,,,percent of total billed charges,,,85.8,,,percent of total billed charges,,,,,,,,,,,,,,,85.8,,,percent of total billed charges,,,85.8,,,percent of total billed charges,,,,,,,,,35.16,,,fee schedule,,,,,,,,,,,,,,,30.48,,,fee schedule,,,40.64,,,fee schedule,,,22.85,,,fee schedule,,,64.35,,,percent of total billed charges,,,85.8,,,percent of total billed charges,,,85.8,,,percent of total billed charges,,,85.8,,,percent of total billed charges,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,50.55,,,percent of total billed charges,,
FAT EMULSION IV 20  250 ML,2500010912,CDM,250,RC,B4185,HCPCS,6332382074,NDC,999,EAPG,,outpatient,facility,250,UN,85.8,85.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENOFIBRATE 54 MG TAB,2500010942,CDM,637,RC,7075621490,NDC,,,,,,inpatient,facility,54,UN,2.61,2.61,0.21,2.61,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,2.61,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,2.22,,,percent of total billed charges,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,
FENOFIBRATE 54 MG TAB,2500010942,CDM,637,RC,7075621490,NDC,,,,,,outpatient,facility,54,UN,2.61,2.61,0.21,548.68,,1.85,,,percent of total billed charges,,,0.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.61,,,percent of total billed charges,,,1.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.96,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.61,,,fee schedule,,,2.61,,,percent of total billed charges,,,,,,,,,2.61,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,,,,,,,1.54,,,percent of total billed charges,,,548.68,,,per diem,,,2.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.61,,,percent of total billed charges,,,2.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,0.97,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,,,,,,,2.61,,,percent of total billed charges,,,2.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,2.43,,,percent of total billed charges,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.54,,,percent of total billed charges,,
FENOFIBRATE 54 MG TAB,2500010942,CDM,637,RC,7075621490,NDC,999,EAPG,,,,outpatient,facility,54,UN,2.61,2.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL TRANSDERM 100 MCG/HR,2500010980,CDM,637,RC,6050570842,NDC,,,,,,inpatient,facility,1,UN,259.74,259.74,20.78,259.74,,,,,,,,,,,,,,259.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,259.74,,,percent of total billed charges,,,,,,,,,259.74,,,percent of total billed charges,,,132.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.84,,,percent of total billed charges,,,,,,,,,,,,,,,259.74,,,percent of total billed charges,,,220.78,,,percent of total billed charges,,,,,,,,,,,,,,,259.74,,,percent of total billed charges,,,137.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,259.74,,,percent of total billed charges,,,,,,,,,,,,,,,20.78,,,percent of total billed charges,,,259.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,259.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.04,,,percent of total billed charges,,
FENTANYL TRANSDERM 100 MCG/HR,2500010980,CDM,637,RC,6050570842,NDC,,,,,,outpatient,facility,1,UN,259.74,259.74,20.78,548.68,,184.18,,,percent of total billed charges,,,63.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,259.74,,,percent of total billed charges,,,162.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,182.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,182.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,259.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,95.06,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,259.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,259.74,,,fee schedule,,,259.74,,,percent of total billed charges,,,,,,,,,259.74,,,percent of total billed charges,,,159.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.06,,,percent of total billed charges,,,,,,,,,,,,,,,140.26,,,percent of total billed charges,,,135.06,,,percent of total billed charges,,,142.86,,,percent of total billed charges,,,,,,,,,153.25,,,percent of total billed charges,,,548.68,,,per diem,,,259.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,259.74,,,percent of total billed charges,,,220.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.95,,,percent of total billed charges,,,259.74,,,percent of total billed charges,,,259.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.22,,,percent of total billed charges,,,210.18,,,percent of total billed charges,,,,,,,,,,,,,,,103.9,,,percent of total billed charges,,,,,,,,,96.1,,,percent of total billed charges,,,96.1,,,percent of total billed charges,,,,,,,,,259.74,,,percent of total billed charges,,,259.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,259.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.78,,,percent of total billed charges,,,259.74,,,percent of total billed charges,,,,,,,,,,,,,,,259.74,,,percent of total billed charges,,,259.74,,,percent of total billed charges,,,,,,,,,241.61,,,percent of total billed charges,,,,,,,,,,,,,,,241.61,,,percent of total billed charges,,,241.61,,,percent of total billed charges,,,241.61,,,percent of total billed charges,,,194.81,,,percent of total billed charges,,,259.74,,,percent of total billed charges,,,259.74,,,percent of total billed charges,,,259.74,,,percent of total billed charges,,,,,,,,,182.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,153.04,,,percent of total billed charges,,
FENTANYL TRANSDERM 100 MCG/HR,2500010980,CDM,637,RC,6050570842,NDC,999,EAPG,,,,outpatient,facility,1,UN,259.74,259.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL TRANSDERM 25 MCG/HR,2500010983,CDM,637,RC,6050570812,NDC,,,,,,inpatient,facility,1,UN,70.19,70.19,5.62,70.19,,,,,,,,,,,,,,70.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.19,,,percent of total billed charges,,,,,,,,,70.19,,,percent of total billed charges,,,35.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.11,,,percent of total billed charges,,,,,,,,,,,,,,,70.19,,,percent of total billed charges,,,59.66,,,percent of total billed charges,,,,,,,,,,,,,,,70.19,,,percent of total billed charges,,,37.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,70.19,,,percent of total billed charges,,,,,,,,,,,,,,,5.62,,,percent of total billed charges,,,70.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.36,,,percent of total billed charges,,
FENTANYL TRANSDERM 25 MCG/HR,2500010983,CDM,637,RC,6050570812,NDC,,,,,,outpatient,facility,1,UN,70.19,70.19,5.62,548.68,,49.77,,,percent of total billed charges,,,17.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,70.19,,,percent of total billed charges,,,43.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,49.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,49.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,70.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,25.69,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,70.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,70.19,,,fee schedule,,,70.19,,,percent of total billed charges,,,,,,,,,70.19,,,percent of total billed charges,,,43.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.01,,,percent of total billed charges,,,,,,,,,,,,,,,37.9,,,percent of total billed charges,,,36.5,,,percent of total billed charges,,,38.6,,,percent of total billed charges,,,,,,,,,41.41,,,percent of total billed charges,,,548.68,,,per diem,,,70.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,70.19,,,percent of total billed charges,,,59.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.28,,,percent of total billed charges,,,70.19,,,percent of total billed charges,,,70.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.35,,,percent of total billed charges,,,56.8,,,percent of total billed charges,,,,,,,,,,,,,,,28.08,,,percent of total billed charges,,,,,,,,,25.97,,,percent of total billed charges,,,25.97,,,percent of total billed charges,,,,,,,,,70.19,,,percent of total billed charges,,,70.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,70.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.62,,,percent of total billed charges,,,70.19,,,percent of total billed charges,,,,,,,,,,,,,,,70.19,,,percent of total billed charges,,,70.19,,,percent of total billed charges,,,,,,,,,65.29,,,percent of total billed charges,,,,,,,,,,,,,,,65.29,,,percent of total billed charges,,,65.29,,,percent of total billed charges,,,65.29,,,percent of total billed charges,,,52.64,,,percent of total billed charges,,,70.19,,,percent of total billed charges,,,70.19,,,percent of total billed charges,,,70.19,,,percent of total billed charges,,,,,,,,,49.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,41.36,,,percent of total billed charges,,
FENTANYL TRANSDERM 25 MCG/HR,2500010983,CDM,637,RC,6050570812,NDC,999,EAPG,,,,outpatient,facility,1,UN,70.19,70.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL TRANSDERM 50 MCG/HR,2500010985,CDM,637,RC,6050570822,NDC,,,,,,inpatient,facility,1,UN,128.3,128.3,10.26,128.3,,,,,,,,,,,,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.3,,,percent of total billed charges,,,,,,,,,128.3,,,percent of total billed charges,,,65.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.98,,,percent of total billed charges,,,,,,,,,,,,,,,128.3,,,percent of total billed charges,,,109.06,,,percent of total billed charges,,,,,,,,,,,,,,,128.3,,,percent of total billed charges,,,68.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,,10.26,,,percent of total billed charges,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.59,,,percent of total billed charges,,
FENTANYL TRANSDERM 50 MCG/HR,2500010985,CDM,637,RC,6050570822,NDC,,,,,,outpatient,facility,1,UN,128.3,128.3,10.26,548.68,,90.98,,,percent of total billed charges,,,31.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,128.3,,,percent of total billed charges,,,80.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,90.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,90.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,46.96,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,128.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,128.3,,,fee schedule,,,128.3,,,percent of total billed charges,,,,,,,,,128.3,,,percent of total billed charges,,,78.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.41,,,percent of total billed charges,,,,,,,,,,,,,,,69.28,,,percent of total billed charges,,,66.72,,,percent of total billed charges,,,70.57,,,percent of total billed charges,,,,,,,,,75.7,,,percent of total billed charges,,,548.68,,,per diem,,,128.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,128.3,,,percent of total billed charges,,,109.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.14,,,percent of total billed charges,,,128.3,,,percent of total billed charges,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.55,,,percent of total billed charges,,,103.82,,,percent of total billed charges,,,,,,,,,,,,,,,51.32,,,percent of total billed charges,,,,,,,,,47.47,,,percent of total billed charges,,,47.47,,,percent of total billed charges,,,,,,,,,128.3,,,percent of total billed charges,,,128.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,128.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.26,,,percent of total billed charges,,,128.3,,,percent of total billed charges,,,,,,,,,,,,,,,128.3,,,percent of total billed charges,,,128.3,,,percent of total billed charges,,,,,,,,,119.34,,,percent of total billed charges,,,,,,,,,,,,,,,119.34,,,percent of total billed charges,,,119.34,,,percent of total billed charges,,,119.34,,,percent of total billed charges,,,96.23,,,percent of total billed charges,,,128.3,,,percent of total billed charges,,,128.3,,,percent of total billed charges,,,128.3,,,percent of total billed charges,,,,,,,,,89.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,75.59,,,percent of total billed charges,,
FENTANYL TRANSDERM 50 MCG/HR,2500010985,CDM,637,RC,6050570822,NDC,999,EAPG,,,,outpatient,facility,1,UN,128.3,128.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL TRANSDERM 75 MCG/HR,2500010988,CDM,637,RC,6050570832,NDC,,,,,,inpatient,facility,1,UN,195.72,195.72,15.66,195.72,,,,,,,,,,,,,,195.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.72,,,percent of total billed charges,,,,,,,,,195.72,,,percent of total billed charges,,,99.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.43,,,percent of total billed charges,,,,,,,,,,,,,,,195.72,,,percent of total billed charges,,,166.36,,,percent of total billed charges,,,,,,,,,,,,,,,195.72,,,percent of total billed charges,,,103.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,195.72,,,percent of total billed charges,,,,,,,,,,,,,,,15.66,,,percent of total billed charges,,,195.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,195.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.32,,,percent of total billed charges,,
FENTANYL TRANSDERM 75 MCG/HR,2500010988,CDM,637,RC,6050570832,NDC,,,,,,outpatient,facility,1,UN,195.72,195.72,15.66,548.68,,138.79,,,percent of total billed charges,,,47.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,195.72,,,percent of total billed charges,,,122.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,137.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,137.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,195.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,71.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,195.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,195.72,,,fee schedule,,,195.72,,,percent of total billed charges,,,,,,,,,195.72,,,percent of total billed charges,,,119.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.45,,,percent of total billed charges,,,,,,,,,,,,,,,105.69,,,percent of total billed charges,,,101.77,,,percent of total billed charges,,,107.65,,,percent of total billed charges,,,,,,,,,115.47,,,percent of total billed charges,,,548.68,,,per diem,,,195.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,195.72,,,percent of total billed charges,,,166.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.95,,,percent of total billed charges,,,195.72,,,percent of total billed charges,,,195.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.03,,,percent of total billed charges,,,158.38,,,percent of total billed charges,,,,,,,,,,,,,,,78.29,,,percent of total billed charges,,,,,,,,,72.42,,,percent of total billed charges,,,72.42,,,percent of total billed charges,,,,,,,,,195.72,,,percent of total billed charges,,,195.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,195.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.66,,,percent of total billed charges,,,195.72,,,percent of total billed charges,,,,,,,,,,,,,,,195.72,,,percent of total billed charges,,,195.72,,,percent of total billed charges,,,,,,,,,182.06,,,percent of total billed charges,,,,,,,,,,,,,,,182.06,,,percent of total billed charges,,,182.06,,,percent of total billed charges,,,182.06,,,percent of total billed charges,,,146.79,,,percent of total billed charges,,,195.72,,,percent of total billed charges,,,195.72,,,percent of total billed charges,,,195.72,,,percent of total billed charges,,,,,,,,,137.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.86,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,115.32,,,percent of total billed charges,,
FENTANYL TRANSDERM 75 MCG/HR,2500010988,CDM,637,RC,6050570832,NDC,999,EAPG,,,,outpatient,facility,1,UN,195.72,195.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FERRIC SUBSULF PASTE 8 ML,2500010997,CDM,250,RC,4878311208,NDC,,,,,,inpatient,facility,8,UN,48.11,48.11,3.85,48.11,,,,,,,,,,,,,,48.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.11,,,percent of total billed charges,,,,,,,,,48.11,,,percent of total billed charges,,,24.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,48.11,,,percent of total billed charges,,,40.89,,,percent of total billed charges,,,,,,,,,,,,,,,48.11,,,percent of total billed charges,,,25.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,48.11,,,percent of total billed charges,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,48.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.35,,,percent of total billed charges,,
FERRIC SUBSULF PASTE 8 ML,2500010997,CDM,250,RC,4878311208,NDC,,,,,,outpatient,facility,8,UN,48.11,48.11,3.85,548.68,,34.11,,,percent of total billed charges,,,11.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,48.11,,,percent of total billed charges,,,30.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,33.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,33.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,48.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,17.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,48.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,48.11,,,fee schedule,,,48.11,,,percent of total billed charges,,,,,,,,,48.11,,,percent of total billed charges,,,29.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,28.38,,,percent of total billed charges,,,548.68,,,per diem,,,48.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,48.11,,,percent of total billed charges,,,40.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.55,,,percent of total billed charges,,,48.11,,,percent of total billed charges,,,48.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.46,,,percent of total billed charges,,,38.93,,,percent of total billed charges,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,,,,,,,48.11,,,percent of total billed charges,,,48.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,48.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.85,,,percent of total billed charges,,,48.11,,,percent of total billed charges,,,,,,,,,,,,,,,48.11,,,percent of total billed charges,,,48.11,,,percent of total billed charges,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,36.08,,,percent of total billed charges,,,48.11,,,percent of total billed charges,,,48.11,,,percent of total billed charges,,,48.11,,,percent of total billed charges,,,,,,,,,33.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,28.35,,,percent of total billed charges,,
FERRIC SUBSULF PASTE 8 ML,2500010997,CDM,250,RC,4878311208,NDC,999,EAPG,,,,outpatient,facility,8,UN,48.11,48.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FERROUS SULF 300 MG/5 ML UDC,2500011033,CDM,637,RC,3932815705,NDC,,,,,,inpatient,facility,5,UN,11.51,11.51,0.92,11.51,,,,,,,,,,,,,,11.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.51,,,percent of total billed charges,,,,,,,,,11.51,,,percent of total billed charges,,,5.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.91,,,percent of total billed charges,,,,,,,,,,,,,,,11.51,,,percent of total billed charges,,,9.78,,,percent of total billed charges,,,,,,,,,,,,,,,11.51,,,percent of total billed charges,,,6.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11.51,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,11.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.78,,,percent of total billed charges,,
FERROUS SULF 300 MG/5 ML UDC,2500011033,CDM,637,RC,3932815705,NDC,,,,,,outpatient,facility,5,UN,11.51,11.51,0.92,548.68,,8.16,,,percent of total billed charges,,,2.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,11.51,,,percent of total billed charges,,,7.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.21,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,11.51,,,fee schedule,,,11.51,,,percent of total billed charges,,,,,,,,,11.51,,,percent of total billed charges,,,7.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.2,,,percent of total billed charges,,,,,,,,,,,,,,,6.22,,,percent of total billed charges,,,5.99,,,percent of total billed charges,,,6.33,,,percent of total billed charges,,,,,,,,,6.79,,,percent of total billed charges,,,548.68,,,per diem,,,11.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11.51,,,percent of total billed charges,,,9.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.11,,,percent of total billed charges,,,11.51,,,percent of total billed charges,,,11.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.76,,,percent of total billed charges,,,9.31,,,percent of total billed charges,,,,,,,,,,,,,,,4.6,,,percent of total billed charges,,,,,,,,,4.26,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,,,,,,,11.51,,,percent of total billed charges,,,11.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.92,,,percent of total billed charges,,,11.51,,,percent of total billed charges,,,,,,,,,,,,,,,11.51,,,percent of total billed charges,,,11.51,,,percent of total billed charges,,,,,,,,,10.71,,,percent of total billed charges,,,,,,,,,,,,,,,10.71,,,percent of total billed charges,,,10.71,,,percent of total billed charges,,,10.71,,,percent of total billed charges,,,8.63,,,percent of total billed charges,,,11.51,,,percent of total billed charges,,,11.51,,,percent of total billed charges,,,11.51,,,percent of total billed charges,,,,,,,,,8.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.78,,,percent of total billed charges,,
FERROUS SULF 300 MG/5 ML UDC,2500011033,CDM,637,RC,3932815705,NDC,999,EAPG,,,,outpatient,facility,5,UN,11.51,11.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FERROUS SULF 325 MG TAB,2500011035,CDM,637,RC,904759161,NDC,,,,,,inpatient,facility,325,UN,1.88,1.88,0.15,1.88,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,
FERROUS SULF 325 MG TAB,2500011035,CDM,637,RC,904759161,NDC,,,,,,outpatient,facility,325,UN,1.88,1.88,0.15,548.68,,1.33,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.88,,,percent of total billed charges,,,1.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.69,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.88,,,fee schedule,,,1.88,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,1.11,,,percent of total billed charges,,,548.68,,,per diem,,,1.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.88,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,0.7,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.11,,,percent of total billed charges,,
FERROUS SULF 325 MG TAB,2500011035,CDM,637,RC,904759161,NDC,999,EAPG,,,,outpatient,facility,325,UN,1.88,1.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FERROUS SULF 220 MG/5 ML UDC,2500011039,CDM,637,RC,5038377816,NDC,,,,,,inpatient,facility,5,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
FERROUS SULF 220 MG/5 ML UDC,2500011039,CDM,637,RC,5038377816,NDC,,,,,,outpatient,facility,5,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
FERROUS SULF 220 MG/5 ML UDC,2500011039,CDM,637,RC,5038377816,NDC,999,EAPG,,,,outpatient,facility,5,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FINASTERIDE 5 MG TAB,2500011070,CDM,637,RC,904683006,NDC,,,,,,inpatient,facility,5,UN,2.24,2.24,0.18,2.24,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,
FINASTERIDE 5 MG TAB,2500011070,CDM,637,RC,904683006,NDC,,,,,,outpatient,facility,5,UN,2.24,2.24,0.18,548.68,,1.59,,,percent of total billed charges,,,0.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.24,,,percent of total billed charges,,,1.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.82,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.24,,,fee schedule,,,2.24,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,548.68,,,per diem,,,2.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.24,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.32,,,percent of total billed charges,,
FINASTERIDE 5 MG TAB,2500011070,CDM,637,RC,904683006,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.24,2.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FISH OIL 1000 MG CAP,2500011075,CDM,637,RC,6050540331,NDC,,,,,,inpatient,facility,1,UN,4.74,4.74,0.38,4.74,,,,,,,,,,,,,,4.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.74,,,percent of total billed charges,,,,,,,,,4.74,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,4.74,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,4.74,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,4.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.79,,,percent of total billed charges,,
FISH OIL 1000 MG CAP,2500011075,CDM,637,RC,6050540331,NDC,,,,,,outpatient,facility,1,UN,4.74,4.74,0.38,548.68,,3.36,,,percent of total billed charges,,,1.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.74,,,percent of total billed charges,,,2.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.74,,,fee schedule,,,4.74,,,percent of total billed charges,,,,,,,,,4.74,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,2.8,,,percent of total billed charges,,,548.68,,,per diem,,,4.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.74,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,4.74,,,percent of total billed charges,,,4.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,3.84,,,percent of total billed charges,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,4.74,,,percent of total billed charges,,,4.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.38,,,percent of total billed charges,,,4.74,,,percent of total billed charges,,,,,,,,,,,,,,,4.74,,,percent of total billed charges,,,4.74,,,percent of total billed charges,,,,,,,,,4.41,,,percent of total billed charges,,,,,,,,,,,,,,,4.41,,,percent of total billed charges,,,4.41,,,percent of total billed charges,,,4.41,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,4.74,,,percent of total billed charges,,,4.74,,,percent of total billed charges,,,4.74,,,percent of total billed charges,,,,,,,,,3.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.37,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.79,,,percent of total billed charges,,
FISH OIL 1000 MG CAP,2500011075,CDM,637,RC,6050540331,NDC,999,EAPG,,,,outpatient,facility,1,UN,4.74,4.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLECAINIDE ACETATE 50 MG TAB,2500011102,CDM,637,RC,5374664101,NDC,,,,,,inpatient,facility,50,UN,8.45,8.45,0.68,8.45,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,8.45,,,percent of total billed charges,,,4.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,7.18,,,percent of total billed charges,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,4.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,
FLECAINIDE ACETATE 50 MG TAB,2500011102,CDM,637,RC,5374664101,NDC,,,,,,outpatient,facility,50,UN,8.45,8.45,0.68,548.68,,5.99,,,percent of total billed charges,,,2.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.45,,,percent of total billed charges,,,5.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.09,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.45,,,fee schedule,,,8.45,,,percent of total billed charges,,,,,,,,,8.45,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,,4.56,,,percent of total billed charges,,,4.39,,,percent of total billed charges,,,4.65,,,percent of total billed charges,,,,,,,,,4.99,,,percent of total billed charges,,,548.68,,,per diem,,,8.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.45,,,percent of total billed charges,,,7.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.49,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,6.84,,,percent of total billed charges,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,3.13,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,,,,,,,8.45,,,percent of total billed charges,,,8.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.68,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,5.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.98,,,percent of total billed charges,,
FLECAINIDE ACETATE 50 MG TAB,2500011102,CDM,637,RC,5374664101,NDC,999,EAPG,,,,outpatient,facility,50,UN,8.45,8.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUCONAZOLE 100 MG TAB,2500011130,CDM,637,RC,904650061,NDC,,,,,,inpatient,facility,100,UN,4.68,4.68,0.37,4.68,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,2.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,
FLUCONAZOLE 100 MG TAB,2500011130,CDM,637,RC,904650061,NDC,,,,,,outpatient,facility,100,UN,4.68,4.68,0.37,548.68,,3.32,,,percent of total billed charges,,,1.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.68,,,percent of total billed charges,,,2.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.68,,,fee schedule,,,4.68,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,2.76,,,percent of total billed charges,,,548.68,,,per diem,,,4.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.68,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.16,,,percent of total billed charges,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,1.73,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.37,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,4.35,,,percent of total billed charges,,,,,,,,,,,,,,,4.35,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.76,,,percent of total billed charges,,
FLUCONAZOLE 100 MG TAB,2500011130,CDM,637,RC,904650061,NDC,999,EAPG,,,,outpatient,facility,100,UN,4.68,4.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUCONAZOLE 200 MG TAB,2500011132,CDM,637,RC,5026833915,NDC,,,,,,inpatient,facility,200,UN,53.82,53.82,4.31,53.82,,,,,,,,,,,,,,53.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.82,,,percent of total billed charges,,,,,,,,,53.82,,,percent of total billed charges,,,27.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.29,,,percent of total billed charges,,,,,,,,,,,,,,,53.82,,,percent of total billed charges,,,45.75,,,percent of total billed charges,,,,,,,,,,,,,,,53.82,,,percent of total billed charges,,,28.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,53.82,,,percent of total billed charges,,,,,,,,,,,,,,,4.31,,,percent of total billed charges,,,53.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.71,,,percent of total billed charges,,
FLUCONAZOLE 200 MG TAB,2500011132,CDM,637,RC,5026833915,NDC,,,,,,outpatient,facility,200,UN,53.82,53.82,4.31,548.68,,38.16,,,percent of total billed charges,,,13.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,53.82,,,percent of total billed charges,,,33.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,37.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,37.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,53.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,19.7,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,53.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,53.82,,,fee schedule,,,53.82,,,percent of total billed charges,,,,,,,,,53.82,,,percent of total billed charges,,,32.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.35,,,percent of total billed charges,,,,,,,,,,,,,,,29.06,,,percent of total billed charges,,,27.99,,,percent of total billed charges,,,29.6,,,percent of total billed charges,,,,,,,,,31.75,,,percent of total billed charges,,,548.68,,,per diem,,,53.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,53.82,,,percent of total billed charges,,,45.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.58,,,percent of total billed charges,,,53.82,,,percent of total billed charges,,,53.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.31,,,percent of total billed charges,,,43.55,,,percent of total billed charges,,,,,,,,,,,,,,,21.53,,,percent of total billed charges,,,,,,,,,19.91,,,percent of total billed charges,,,19.91,,,percent of total billed charges,,,,,,,,,53.82,,,percent of total billed charges,,,53.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,53.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.31,,,percent of total billed charges,,,53.82,,,percent of total billed charges,,,,,,,,,,,,,,,53.82,,,percent of total billed charges,,,53.82,,,percent of total billed charges,,,,,,,,,50.06,,,percent of total billed charges,,,,,,,,,,,,,,,50.06,,,percent of total billed charges,,,50.06,,,percent of total billed charges,,,50.06,,,percent of total billed charges,,,40.37,,,percent of total billed charges,,,53.82,,,percent of total billed charges,,,53.82,,,percent of total billed charges,,,53.82,,,percent of total billed charges,,,,,,,,,37.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,31.71,,,percent of total billed charges,,
FLUCONAZOLE 200 MG TAB,2500011132,CDM,637,RC,5026833915,NDC,999,EAPG,,,,outpatient,facility,200,UN,53.82,53.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUCONAZOLE 40 MG ML 35 ML BTL,2500011136,CDM,637,RC,5723715035,NDC,,,,,,inpatient,facility,5,UN,61.48,61.48,4.92,61.48,,,,,,,,,,,,,,61.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.48,,,percent of total billed charges,,,,,,,,,61.48,,,percent of total billed charges,,,31.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.89,,,percent of total billed charges,,,,,,,,,,,,,,,61.48,,,percent of total billed charges,,,52.26,,,percent of total billed charges,,,,,,,,,,,,,,,61.48,,,percent of total billed charges,,,32.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,61.48,,,percent of total billed charges,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,61.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.22,,,percent of total billed charges,,
FLUCONAZOLE 40 MG ML 35 ML BTL,2500011136,CDM,637,RC,5723715035,NDC,,,,,,outpatient,facility,5,UN,61.48,61.48,4.92,548.68,,43.6,,,percent of total billed charges,,,15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,61.48,,,percent of total billed charges,,,38.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,43.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,43.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,61.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,22.5,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,61.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,61.48,,,fee schedule,,,61.48,,,percent of total billed charges,,,,,,,,,61.48,,,percent of total billed charges,,,37.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.8,,,percent of total billed charges,,,,,,,,,,,,,,,33.2,,,percent of total billed charges,,,31.97,,,percent of total billed charges,,,33.81,,,percent of total billed charges,,,,,,,,,36.27,,,percent of total billed charges,,,548.68,,,per diem,,,61.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,61.48,,,percent of total billed charges,,,52.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.65,,,percent of total billed charges,,,61.48,,,percent of total billed charges,,,61.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.47,,,percent of total billed charges,,,49.75,,,percent of total billed charges,,,,,,,,,,,,,,,24.59,,,percent of total billed charges,,,,,,,,,22.75,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,,,,,,,61.48,,,percent of total billed charges,,,61.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,61.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.92,,,percent of total billed charges,,,61.48,,,percent of total billed charges,,,,,,,,,,,,,,,61.48,,,percent of total billed charges,,,61.48,,,percent of total billed charges,,,,,,,,,57.19,,,percent of total billed charges,,,,,,,,,,,,,,,57.19,,,percent of total billed charges,,,57.19,,,percent of total billed charges,,,57.19,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,61.48,,,percent of total billed charges,,,61.48,,,percent of total billed charges,,,61.48,,,percent of total billed charges,,,,,,,,,43.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,36.22,,,percent of total billed charges,,
FLUCONAZOLE 40 MG ML 35 ML BTL,2500011136,CDM,637,RC,5723715035,NDC,999,EAPG,,,,outpatient,facility,5,UN,61.48,61.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUDROCORTISONE 0.1 MG TAB,2500011150,CDM,637,RC,5026833015,NDC,,,,,,inpatient,facility,0.1,UN,5.28,5.28,0.42,5.28,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,5.28,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,4.49,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.11,,,percent of total billed charges,,
FLUDROCORTISONE 0.1 MG TAB,2500011150,CDM,637,RC,5026833015,NDC,,,,,,outpatient,facility,0.1,UN,5.28,5.28,0.42,548.68,,3.74,,,percent of total billed charges,,,1.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.28,,,percent of total billed charges,,,3.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.93,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.28,,,fee schedule,,,5.28,,,percent of total billed charges,,,,,,,,,5.28,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,3.12,,,percent of total billed charges,,,548.68,,,per diem,,,5.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.28,,,percent of total billed charges,,,4.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,4.27,,,percent of total billed charges,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,5.28,,,percent of total billed charges,,,5.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.42,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,3.96,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,3.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.11,,,percent of total billed charges,,
FLUDROCORTISONE 0.1 MG TAB,2500011150,CDM,637,RC,5026833015,NDC,999,EAPG,,,,outpatient,facility,0.1,UN,5.28,5.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUMAZENIL 0.1 MG/ML 5 ML INJ,2500011160,CDM,250,RC,J3490,HCPCS,3600014810,NDC,,,,inpatient,facility,5,UN,23.4,23.4,1.87,23.4,,,,,,,,,,,,,,23.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.4,,,percent of total billed charges,,,,,,,,,23.4,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,23.4,,,percent of total billed charges,,,19.89,,,percent of total billed charges,,,,,,,,,,,,,,,23.4,,,percent of total billed charges,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,23.4,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,23.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.79,,,percent of total billed charges,,
FLUMAZENIL 0.1 MG/ML 5 ML INJ,2500011160,CDM,250,RC,J3490,HCPCS,3600014810,NDC,,,,outpatient,facility,5,UN,23.4,23.4,1.2,548.68,,16.59,,,percent of total billed charges,,,5.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,23.4,,,percent of total billed charges,,,14.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,16.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,16.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,23.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,23.4,,,fee schedule,,,23.4,,,percent of total billed charges,,,,,,,,,23.4,,,percent of total billed charges,,,14.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,23.4,,,percent of total billed charges,,,23.4,,,percent of total billed charges,,,23.4,,,percent of total billed charges,,,,,,,,,13.81,,,percent of total billed charges,,,548.68,,,per diem,,,23.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,23.4,,,percent of total billed charges,,,19.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.79,,,percent of total billed charges,,,18.94,,,percent of total billed charges,,,,,,,,,,,,,,,9.36,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,23.4,,,percent of total billed charges,,,23.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.87,,,percent of total billed charges,,,23.4,,,percent of total billed charges,,,,,,,,,,,,,,,23.4,,,percent of total billed charges,,,23.4,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,17.55,,,percent of total billed charges,,,23.4,,,percent of total billed charges,,,23.4,,,percent of total billed charges,,,23.4,,,percent of total billed charges,,,,,,,,,16.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.79,,,percent of total billed charges,,
FLUMAZENIL 0.1 MG/ML 5 ML INJ,2500011160,CDM,250,RC,J3490,HCPCS,3600014810,NDC,435,EAPG,,outpatient,facility,5,UN,23.4,23.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUOCINONIDE 0.05  CR 15 GM,2500011210,CDM,637,RC,5167212791,NDC,,,,,,inpatient,facility,15,UN,150.32,150.32,12.03,150.32,,,,,,,,,,,,,,150.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.32,,,percent of total billed charges,,,,,,,,,150.32,,,percent of total billed charges,,,76.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.19,,,percent of total billed charges,,,,,,,,,,,,,,,150.32,,,percent of total billed charges,,,127.77,,,percent of total billed charges,,,,,,,,,,,,,,,150.32,,,percent of total billed charges,,,79.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,150.32,,,percent of total billed charges,,,,,,,,,,,,,,,12.03,,,percent of total billed charges,,,150.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.57,,,percent of total billed charges,,
FLUOCINONIDE 0.05  CR 15 GM,2500011210,CDM,637,RC,5167212791,NDC,,,,,,outpatient,facility,15,UN,150.32,150.32,12.03,548.68,,106.59,,,percent of total billed charges,,,36.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,150.32,,,percent of total billed charges,,,94.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,105.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,105.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,150.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,55.02,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,150.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,150.32,,,fee schedule,,,150.32,,,percent of total billed charges,,,,,,,,,150.32,,,percent of total billed charges,,,92.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.1,,,percent of total billed charges,,,,,,,,,,,,,,,81.17,,,percent of total billed charges,,,78.17,,,percent of total billed charges,,,82.68,,,percent of total billed charges,,,,,,,,,88.69,,,percent of total billed charges,,,548.68,,,per diem,,,150.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,150.32,,,percent of total billed charges,,,127.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.83,,,percent of total billed charges,,,150.32,,,percent of total billed charges,,,150.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.41,,,percent of total billed charges,,,121.64,,,percent of total billed charges,,,,,,,,,,,,,,,60.13,,,percent of total billed charges,,,,,,,,,55.62,,,percent of total billed charges,,,55.62,,,percent of total billed charges,,,,,,,,,150.32,,,percent of total billed charges,,,150.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,150.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.03,,,percent of total billed charges,,,150.32,,,percent of total billed charges,,,,,,,,,,,,,,,150.32,,,percent of total billed charges,,,150.32,,,percent of total billed charges,,,,,,,,,139.83,,,percent of total billed charges,,,,,,,,,,,,,,,139.83,,,percent of total billed charges,,,139.83,,,percent of total billed charges,,,139.83,,,percent of total billed charges,,,112.74,,,percent of total billed charges,,,150.32,,,percent of total billed charges,,,150.32,,,percent of total billed charges,,,150.32,,,percent of total billed charges,,,,,,,,,105.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,88.57,,,percent of total billed charges,,
FLUOCINONIDE 0.05  CR 15 GM,2500011210,CDM,637,RC,5167212791,NDC,999,EAPG,,,,outpatient,facility,15,UN,150.32,150.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUOCINONIDE 0.05  OINT 30 GM,2500011216,CDM,637,RC,5167212642,NDC,,,,,,inpatient,facility,30,UN,466.95,466.95,37.36,466.95,,,,,,,,,,,,,,466.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.95,,,percent of total billed charges,,,,,,,,,466.95,,,percent of total billed charges,,,238.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.17,,,percent of total billed charges,,,,,,,,,,,,,,,466.95,,,percent of total billed charges,,,396.91,,,percent of total billed charges,,,,,,,,,,,,,,,466.95,,,percent of total billed charges,,,248,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,466.95,,,percent of total billed charges,,,,,,,,,,,,,,,37.36,,,percent of total billed charges,,,466.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,466.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,275.13,,,percent of total billed charges,,
FLUOCINONIDE 0.05  OINT 30 GM,2500011216,CDM,637,RC,5167212642,NDC,,,,,,outpatient,facility,30,UN,466.95,466.95,37.36,548.68,,331.11,,,percent of total billed charges,,,113.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,466.95,,,percent of total billed charges,,,292.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,328.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,328.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,466.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,170.9,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,466.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,466.95,,,fee schedule,,,466.95,,,percent of total billed charges,,,,,,,,,466.95,,,percent of total billed charges,,,286.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.7,,,percent of total billed charges,,,,,,,,,,,,,,,252.15,,,percent of total billed charges,,,242.81,,,percent of total billed charges,,,256.82,,,percent of total billed charges,,,,,,,,,275.5,,,percent of total billed charges,,,548.68,,,per diem,,,466.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,466.95,,,percent of total billed charges,,,396.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,248,,,percent of total billed charges,,,466.95,,,percent of total billed charges,,,466.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315,,,percent of total billed charges,,,377.86,,,percent of total billed charges,,,,,,,,,,,,,,,186.78,,,percent of total billed charges,,,,,,,,,172.77,,,percent of total billed charges,,,172.77,,,percent of total billed charges,,,,,,,,,466.95,,,percent of total billed charges,,,466.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,466.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,37.36,,,percent of total billed charges,,,466.95,,,percent of total billed charges,,,,,,,,,,,,,,,466.95,,,percent of total billed charges,,,466.95,,,percent of total billed charges,,,,,,,,,434.36,,,percent of total billed charges,,,,,,,,,,,,,,,434.36,,,percent of total billed charges,,,434.36,,,percent of total billed charges,,,434.36,,,percent of total billed charges,,,350.21,,,percent of total billed charges,,,466.95,,,percent of total billed charges,,,466.95,,,percent of total billed charges,,,466.95,,,percent of total billed charges,,,,,,,,,327.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,275.13,,,percent of total billed charges,,
FLUOCINONIDE 0.05  OINT 30 GM,2500011216,CDM,637,RC,5167212642,NDC,999,EAPG,,,,outpatient,facility,30,UN,466.95,466.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUORESCEIN SOD 500 MG/5 ML,2500011221,CDM,250,RC,8129886603,NDC,,,,,,inpatient,facility,5,UN,237.6,237.6,19.01,237.6,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,,,,,,,237.6,,,percent of total billed charges,,,121.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.56,,,percent of total billed charges,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,201.96,,,percent of total billed charges,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,126.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,19.01,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.99,,,percent of total billed charges,,
FLUORESCEIN SOD 500 MG/5 ML,2500011221,CDM,250,RC,8129886603,NDC,,,,,,outpatient,facility,5,UN,237.6,237.6,19.01,548.68,,168.48,,,percent of total billed charges,,,57.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,237.6,,,percent of total billed charges,,,148.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,167.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,167.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,86.96,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,237.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,237.6,,,fee schedule,,,237.6,,,percent of total billed charges,,,,,,,,,237.6,,,percent of total billed charges,,,145.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,140.18,,,percent of total billed charges,,,548.68,,,per diem,,,237.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,237.6,,,percent of total billed charges,,,201.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.19,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.28,,,percent of total billed charges,,,192.27,,,percent of total billed charges,,,,,,,,,,,,,,,95.04,,,percent of total billed charges,,,,,,,,,95.04,,,percent of total billed charges,,,95.04,,,percent of total billed charges,,,,,,,,,237.6,,,percent of total billed charges,,,237.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,237.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.01,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,,,,,,,95.04,,,percent of total billed charges,,,,,,,,,,,,,,,95.04,,,percent of total billed charges,,,95.04,,,percent of total billed charges,,,95.04,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,,,,,,,166.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,139.99,,,percent of total billed charges,,
FLUORESCEIN SOD 500 MG/5 ML,2500011221,CDM,250,RC,8129886603,NDC,999,EAPG,,,,outpatient,facility,5,UN,237.6,237.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUORESCEIN SOD OPH 1 MG STRP,2500011226,CDM,637,RC,1723890030,NDC,,,,,,inpatient,facility,1,UN,0.69,0.69,0.06,0.69,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,
FLUORESCEIN SOD OPH 1 MG STRP,2500011226,CDM,637,RC,1723890030,NDC,,,,,,outpatient,facility,1,UN,0.69,0.69,0.06,548.68,,0.49,,,percent of total billed charges,,,0.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.69,,,percent of total billed charges,,,0.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.69,,,fee schedule,,,0.69,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,0.41,,,percent of total billed charges,,,548.68,,,per diem,,,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.69,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.41,,,percent of total billed charges,,
FLUORESCEIN SOD OPH 1 MG STRP,2500011226,CDM,637,RC,1723890030,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.69,0.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUOROURACIL 5  40 GM CRM,2500011263,CDM,637,RC,5167241186,NDC,,,,,,inpatient,facility,40,UN,1270.3,1270.3,101.62,1270.3,,,,,,,,,,,,,,1270.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1270.3,,,percent of total billed charges,,,,,,,,,1270.3,,,percent of total billed charges,,,648.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1081.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,762.18,,,percent of total billed charges,,,,,,,,,,,,,,,1270.3,,,percent of total billed charges,,,1079.75,,,percent of total billed charges,,,,,,,,,,,,,,,1270.3,,,percent of total billed charges,,,674.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1270.3,,,percent of total billed charges,,,,,,,,,,,,,,,101.62,,,percent of total billed charges,,,1270.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1270.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,748.46,,,percent of total billed charges,,
FLUOROURACIL 5  40 GM CRM,2500011263,CDM,637,RC,5167241186,NDC,,,,,,outpatient,facility,40,UN,1270.3,1270.3,101.62,1270.3,,900.77,,,percent of total billed charges,,,309.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1270.3,,,percent of total billed charges,,,796.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,893.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,893.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1270.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,464.93,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1270.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1270.3,,,fee schedule,,,1270.3,,,percent of total billed charges,,,,,,,,,1270.3,,,percent of total billed charges,,,778.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,905.09,,,percent of total billed charges,,,,,,,,,,,,,,,685.96,,,percent of total billed charges,,,660.56,,,percent of total billed charges,,,698.67,,,percent of total billed charges,,,,,,,,,749.48,,,percent of total billed charges,,,548.68,,,per diem,,,1270.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1270.3,,,percent of total billed charges,,,1079.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,674.66,,,percent of total billed charges,,,1270.3,,,percent of total billed charges,,,1270.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,856.94,,,percent of total billed charges,,,1027.93,,,percent of total billed charges,,,,,,,,,,,,,,,508.12,,,percent of total billed charges,,,,,,,,,470.01,,,percent of total billed charges,,,470.01,,,percent of total billed charges,,,,,,,,,1270.3,,,percent of total billed charges,,,1270.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1270.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,101.62,,,percent of total billed charges,,,1270.3,,,percent of total billed charges,,,,,,,,,,,,,,,1270.3,,,percent of total billed charges,,,1270.3,,,percent of total billed charges,,,,,,,,,1181.63,,,percent of total billed charges,,,,,,,,,,,,,,,1181.63,,,percent of total billed charges,,,1181.63,,,percent of total billed charges,,,1181.63,,,percent of total billed charges,,,952.72,,,percent of total billed charges,,,1270.3,,,percent of total billed charges,,,1270.3,,,percent of total billed charges,,,1270.3,,,percent of total billed charges,,,,,,,,,890.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,635.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,748.46,,,percent of total billed charges,,
FLUOROURACIL 5  40 GM CRM,2500011263,CDM,637,RC,5167241186,NDC,999,EAPG,,,,outpatient,facility,40,UN,1270.3,1270.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUOXETINE HCL 10 MG CAP,2500011272,CDM,637,RC,904578461,NDC,,,,,,inpatient,facility,10,UN,0.29,0.29,0.02,0.29,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,
FLUOXETINE HCL 10 MG CAP,2500011272,CDM,637,RC,904578461,NDC,,,,,,outpatient,facility,10,UN,0.29,0.29,0.02,548.68,,0.21,,,percent of total billed charges,,,0.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.29,,,percent of total billed charges,,,0.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.29,,,fee schedule,,,0.29,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,0.17,,,percent of total billed charges,,,548.68,,,per diem,,,0.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.29,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,0.11,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.17,,,percent of total billed charges,,
FLUOXETINE HCL 10 MG CAP,2500011272,CDM,637,RC,904578461,NDC,999,EAPG,,,,outpatient,facility,10,UN,0.29,0.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUOXETINE HCL 20 MG CAP,2500011274,CDM,637,RC,904578561,NDC,,,,,,inpatient,facility,20,UN,0.29,0.29,0.02,0.29,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,
FLUOXETINE HCL 20 MG CAP,2500011274,CDM,637,RC,904578561,NDC,,,,,,outpatient,facility,20,UN,0.29,0.29,0.02,548.68,,0.21,,,percent of total billed charges,,,0.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.29,,,percent of total billed charges,,,0.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.29,,,fee schedule,,,0.29,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,0.17,,,percent of total billed charges,,,548.68,,,per diem,,,0.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.29,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,0.11,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.17,,,percent of total billed charges,,
FLUOXETINE HCL 20 MG CAP,2500011274,CDM,637,RC,904578561,NDC,999,EAPG,,,,outpatient,facility,20,UN,0.29,0.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUOXETINE HCL 20 MG/5 ML UDC,2500011277,CDM,637,RC,6068724477,NDC,,,,,,inpatient,facility,5,UN,23.27,23.27,1.86,23.27,,,,,,,,,,,,,,23.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.27,,,percent of total billed charges,,,,,,,,,23.27,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.96,,,percent of total billed charges,,,,,,,,,,,,,,,23.27,,,percent of total billed charges,,,19.78,,,percent of total billed charges,,,,,,,,,,,,,,,23.27,,,percent of total billed charges,,,12.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,23.27,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,23.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.71,,,percent of total billed charges,,
FLUOXETINE HCL 20 MG/5 ML UDC,2500011277,CDM,637,RC,6068724477,NDC,,,,,,outpatient,facility,5,UN,23.27,23.27,1.86,548.68,,16.5,,,percent of total billed charges,,,5.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,23.27,,,percent of total billed charges,,,14.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,16.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,16.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,23.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.52,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,23.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,23.27,,,fee schedule,,,23.27,,,percent of total billed charges,,,,,,,,,23.27,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.58,,,percent of total billed charges,,,,,,,,,,,,,,,12.57,,,percent of total billed charges,,,12.1,,,percent of total billed charges,,,12.8,,,percent of total billed charges,,,,,,,,,13.73,,,percent of total billed charges,,,548.68,,,per diem,,,23.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,23.27,,,percent of total billed charges,,,19.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.36,,,percent of total billed charges,,,23.27,,,percent of total billed charges,,,23.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.7,,,percent of total billed charges,,,18.83,,,percent of total billed charges,,,,,,,,,,,,,,,9.31,,,percent of total billed charges,,,,,,,,,8.61,,,percent of total billed charges,,,8.61,,,percent of total billed charges,,,,,,,,,23.27,,,percent of total billed charges,,,23.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.86,,,percent of total billed charges,,,23.27,,,percent of total billed charges,,,,,,,,,,,,,,,23.27,,,percent of total billed charges,,,23.27,,,percent of total billed charges,,,,,,,,,21.65,,,percent of total billed charges,,,,,,,,,,,,,,,21.65,,,percent of total billed charges,,,21.65,,,percent of total billed charges,,,21.65,,,percent of total billed charges,,,17.45,,,percent of total billed charges,,,23.27,,,percent of total billed charges,,,23.27,,,percent of total billed charges,,,23.27,,,percent of total billed charges,,,,,,,,,16.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.71,,,percent of total billed charges,,
FLUOXETINE HCL 20 MG/5 ML UDC,2500011277,CDM,637,RC,6068724477,NDC,999,EAPG,,,,outpatient,facility,5,UN,23.27,23.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUPHENAZINE 1 MG TAB,2500011300,CDM,637,RC,527178801,NDC,,,,,,inpatient,facility,1,UN,14.48,14.48,1.16,14.48,,,,,,,,,,,,,,14.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.48,,,percent of total billed charges,,,,,,,,,14.48,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.69,,,percent of total billed charges,,,,,,,,,,,,,,,14.48,,,percent of total billed charges,,,12.31,,,percent of total billed charges,,,,,,,,,,,,,,,14.48,,,percent of total billed charges,,,7.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.48,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,14.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.53,,,percent of total billed charges,,
FLUPHENAZINE 1 MG TAB,2500011300,CDM,637,RC,527178801,NDC,,,,,,outpatient,facility,1,UN,14.48,14.48,1.16,548.68,,10.27,,,percent of total billed charges,,,3.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.48,,,percent of total billed charges,,,9.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.48,,,fee schedule,,,14.48,,,percent of total billed charges,,,,,,,,,14.48,,,percent of total billed charges,,,8.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.32,,,percent of total billed charges,,,,,,,,,,,,,,,7.82,,,percent of total billed charges,,,7.53,,,percent of total billed charges,,,7.96,,,percent of total billed charges,,,,,,,,,8.54,,,percent of total billed charges,,,548.68,,,per diem,,,14.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.48,,,percent of total billed charges,,,12.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.69,,,percent of total billed charges,,,14.48,,,percent of total billed charges,,,14.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.77,,,percent of total billed charges,,,11.72,,,percent of total billed charges,,,,,,,,,,,,,,,5.79,,,percent of total billed charges,,,,,,,,,5.36,,,percent of total billed charges,,,5.36,,,percent of total billed charges,,,,,,,,,14.48,,,percent of total billed charges,,,14.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.16,,,percent of total billed charges,,,14.48,,,percent of total billed charges,,,,,,,,,,,,,,,14.48,,,percent of total billed charges,,,14.48,,,percent of total billed charges,,,,,,,,,13.47,,,percent of total billed charges,,,,,,,,,,,,,,,13.47,,,percent of total billed charges,,,13.47,,,percent of total billed charges,,,13.47,,,percent of total billed charges,,,10.86,,,percent of total billed charges,,,14.48,,,percent of total billed charges,,,14.48,,,percent of total billed charges,,,14.48,,,percent of total billed charges,,,,,,,,,10.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.53,,,percent of total billed charges,,
FLUPHENAZINE 1 MG TAB,2500011300,CDM,637,RC,527178801,NDC,999,EAPG,,,,outpatient,facility,1,UN,14.48,14.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUPHENAZINE 2.5 MG TAB,2500011302,CDM,637,RC,527178901,NDC,,,,,,inpatient,facility,2.5,UN,22.44,22.44,1.8,22.44,,,,,,,,,,,,,,22.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.44,,,percent of total billed charges,,,,,,,,,22.44,,,percent of total billed charges,,,11.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,,,,,,,,,,,,,22.44,,,percent of total billed charges,,,19.07,,,percent of total billed charges,,,,,,,,,,,,,,,22.44,,,percent of total billed charges,,,11.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,22.44,,,percent of total billed charges,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,22.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.22,,,percent of total billed charges,,
FLUPHENAZINE 2.5 MG TAB,2500011302,CDM,637,RC,527178901,NDC,,,,,,outpatient,facility,2.5,UN,22.44,22.44,1.8,548.68,,15.91,,,percent of total billed charges,,,5.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,22.44,,,percent of total billed charges,,,14.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,15.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,15.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,22.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.21,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,22.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,22.44,,,fee schedule,,,22.44,,,percent of total billed charges,,,,,,,,,22.44,,,percent of total billed charges,,,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.99,,,percent of total billed charges,,,,,,,,,,,,,,,12.12,,,percent of total billed charges,,,11.67,,,percent of total billed charges,,,12.34,,,percent of total billed charges,,,,,,,,,13.24,,,percent of total billed charges,,,548.68,,,per diem,,,22.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,22.44,,,percent of total billed charges,,,19.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.92,,,percent of total billed charges,,,22.44,,,percent of total billed charges,,,22.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.14,,,percent of total billed charges,,,18.16,,,percent of total billed charges,,,,,,,,,,,,,,,8.98,,,percent of total billed charges,,,,,,,,,8.3,,,percent of total billed charges,,,8.3,,,percent of total billed charges,,,,,,,,,22.44,,,percent of total billed charges,,,22.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.8,,,percent of total billed charges,,,22.44,,,percent of total billed charges,,,,,,,,,,,,,,,22.44,,,percent of total billed charges,,,22.44,,,percent of total billed charges,,,,,,,,,20.87,,,percent of total billed charges,,,,,,,,,,,,,,,20.87,,,percent of total billed charges,,,20.87,,,percent of total billed charges,,,20.87,,,percent of total billed charges,,,16.83,,,percent of total billed charges,,,22.44,,,percent of total billed charges,,,22.44,,,percent of total billed charges,,,22.44,,,percent of total billed charges,,,,,,,,,15.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.22,,,percent of total billed charges,,
FLUPHENAZINE 2.5 MG TAB,2500011302,CDM,637,RC,527178901,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,22.44,22.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUPHENAZINE 2.5MG/ML 10ML INJ,2500011303,CDM,250,RC,6332328110,NDC,,,,,,inpatient,facility,10,UN,633.83,633.83,50.71,633.83,,,,,,,,,,,,,,633.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,633.83,,,percent of total billed charges,,,,,,,,,633.83,,,percent of total billed charges,,,323.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,539.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,380.3,,,percent of total billed charges,,,,,,,,,,,,,,,633.83,,,percent of total billed charges,,,538.76,,,percent of total billed charges,,,,,,,,,,,,,,,633.83,,,percent of total billed charges,,,336.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,633.83,,,percent of total billed charges,,,,,,,,,,,,,,,50.71,,,percent of total billed charges,,,633.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,633.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.45,,,percent of total billed charges,,
FLUPHENAZINE 2.5MG/ML 10ML INJ,2500011303,CDM,250,RC,6332328110,NDC,,,,,,outpatient,facility,10,UN,633.83,633.83,50.71,633.83,,449.45,,,percent of total billed charges,,,154.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,633.83,,,percent of total billed charges,,,397.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,445.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,445.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,633.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,231.98,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,633.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,633.83,,,fee schedule,,,633.83,,,percent of total billed charges,,,,,,,,,633.83,,,percent of total billed charges,,,388.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,451.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,373.96,,,percent of total billed charges,,,548.68,,,per diem,,,633.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,633.83,,,percent of total billed charges,,,538.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,336.63,,,percent of total billed charges,,,633.83,,,percent of total billed charges,,,633.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,427.58,,,percent of total billed charges,,,512.9,,,percent of total billed charges,,,,,,,,,,,,,,,253.53,,,percent of total billed charges,,,,,,,,,253.53,,,percent of total billed charges,,,253.53,,,percent of total billed charges,,,,,,,,,633.83,,,percent of total billed charges,,,633.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,633.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,50.71,,,percent of total billed charges,,,633.83,,,percent of total billed charges,,,,,,,,,,,,,,,633.83,,,percent of total billed charges,,,633.83,,,percent of total billed charges,,,,,,,,,253.53,,,percent of total billed charges,,,,,,,,,,,,,,,253.53,,,percent of total billed charges,,,253.53,,,percent of total billed charges,,,253.53,,,percent of total billed charges,,,475.37,,,percent of total billed charges,,,633.83,,,percent of total billed charges,,,633.83,,,percent of total billed charges,,,633.83,,,percent of total billed charges,,,,,,,,,444.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,373.45,,,percent of total billed charges,,
FLUPHENAZINE 2.5MG/ML 10ML INJ,2500011303,CDM,250,RC,6332328110,NDC,999,EAPG,,,,outpatient,facility,10,UN,633.83,633.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUPHENAZINE 5 MG TAB,2500011305,CDM,637,RC,527179001,NDC,,,,,,inpatient,facility,5,UN,30.36,30.36,2.43,30.36,,,,,,,,,,,,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.36,,,percent of total billed charges,,,,,,,,,30.36,,,percent of total billed charges,,,15.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.22,,,percent of total billed charges,,,,,,,,,,,,,,,30.36,,,percent of total billed charges,,,25.81,,,percent of total billed charges,,,,,,,,,,,,,,,30.36,,,percent of total billed charges,,,16.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.89,,,percent of total billed charges,,
FLUPHENAZINE 5 MG TAB,2500011305,CDM,637,RC,527179001,NDC,,,,,,outpatient,facility,5,UN,30.36,30.36,2.43,548.68,,21.53,,,percent of total billed charges,,,7.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,30.36,,,percent of total billed charges,,,19.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,21.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,21.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,30.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,30.36,,,fee schedule,,,30.36,,,percent of total billed charges,,,,,,,,,30.36,,,percent of total billed charges,,,18.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.63,,,percent of total billed charges,,,,,,,,,,,,,,,16.39,,,percent of total billed charges,,,15.79,,,percent of total billed charges,,,16.7,,,percent of total billed charges,,,,,,,,,17.91,,,percent of total billed charges,,,548.68,,,per diem,,,30.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,30.36,,,percent of total billed charges,,,25.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.12,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,24.57,,,percent of total billed charges,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,11.23,,,percent of total billed charges,,,11.23,,,percent of total billed charges,,,,,,,,,30.36,,,percent of total billed charges,,,30.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.43,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,,,,,,,30.36,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,28.24,,,percent of total billed charges,,,,,,,,,,,,,,,28.24,,,percent of total billed charges,,,28.24,,,percent of total billed charges,,,28.24,,,percent of total billed charges,,,22.77,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,30.36,,,percent of total billed charges,,,,,,,,,21.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.89,,,percent of total billed charges,,
FLUPHENAZINE 5 MG TAB,2500011305,CDM,637,RC,527179001,NDC,999,EAPG,,,,outpatient,facility,5,UN,30.36,30.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLURBIPROFEN 0.03  OPH 2.5 ML,2500011330,CDM,637,RC,6929272225,NDC,,,,,,inpatient,facility,2.5,UN,142.56,142.56,11.4,142.56,,,,,,,,,,,,,,142.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.56,,,percent of total billed charges,,,,,,,,,142.56,,,percent of total billed charges,,,72.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.54,,,percent of total billed charges,,,,,,,,,,,,,,,142.56,,,percent of total billed charges,,,121.18,,,percent of total billed charges,,,,,,,,,,,,,,,142.56,,,percent of total billed charges,,,75.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,142.56,,,percent of total billed charges,,,,,,,,,,,,,,,11.4,,,percent of total billed charges,,,142.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,percent of total billed charges,,
FLURBIPROFEN 0.03  OPH 2.5 ML,2500011330,CDM,637,RC,6929272225,NDC,,,,,,outpatient,facility,2.5,UN,142.56,142.56,11.4,548.68,,101.09,,,percent of total billed charges,,,34.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,142.56,,,percent of total billed charges,,,89.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,100.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,100.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,142.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,52.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,142.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,142.56,,,fee schedule,,,142.56,,,percent of total billed charges,,,,,,,,,142.56,,,percent of total billed charges,,,87.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.57,,,percent of total billed charges,,,,,,,,,,,,,,,76.98,,,percent of total billed charges,,,74.13,,,percent of total billed charges,,,78.41,,,percent of total billed charges,,,,,,,,,84.11,,,percent of total billed charges,,,548.68,,,per diem,,,142.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,142.56,,,percent of total billed charges,,,121.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,75.71,,,percent of total billed charges,,,142.56,,,percent of total billed charges,,,142.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.17,,,percent of total billed charges,,,115.36,,,percent of total billed charges,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,,,,52.75,,,percent of total billed charges,,,52.75,,,percent of total billed charges,,,,,,,,,142.56,,,percent of total billed charges,,,142.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,142.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.4,,,percent of total billed charges,,,142.56,,,percent of total billed charges,,,,,,,,,,,,,,,142.56,,,percent of total billed charges,,,142.56,,,percent of total billed charges,,,,,,,,,132.61,,,percent of total billed charges,,,,,,,,,,,,,,,132.61,,,percent of total billed charges,,,132.61,,,percent of total billed charges,,,132.61,,,percent of total billed charges,,,106.92,,,percent of total billed charges,,,142.56,,,percent of total billed charges,,,142.56,,,percent of total billed charges,,,142.56,,,percent of total billed charges,,,,,,,,,99.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,84,,,percent of total billed charges,,
FLURBIPROFEN 0.03  OPH 2.5 ML,2500011330,CDM,637,RC,6929272225,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,142.56,142.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUTICSN/SALMT 230/21 HFA 8 GM,2500011366,CDM,637,RC,173071722,NDC,,,,,,inpatient,facility,8,UN,843.98,843.98,67.52,843.98,,,,,,,,,,,,,,843.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,843.98,,,percent of total billed charges,,,,,,,,,843.98,,,percent of total billed charges,,,430.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,718.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,506.39,,,percent of total billed charges,,,,,,,,,,,,,,,843.98,,,percent of total billed charges,,,717.38,,,percent of total billed charges,,,,,,,,,,,,,,,843.98,,,percent of total billed charges,,,448.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,843.98,,,percent of total billed charges,,,,,,,,,,,,,,,67.52,,,percent of total billed charges,,,843.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,843.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,497.27,,,percent of total billed charges,,
FLUTICSN/SALMT 230/21 HFA 8 GM,2500011366,CDM,637,RC,173071722,NDC,,,,,,outpatient,facility,8,UN,843.98,843.98,67.52,843.98,,598.47,,,percent of total billed charges,,,205.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,843.98,,,percent of total billed charges,,,528.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,593.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,593.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,843.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,308.9,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,843.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,843.98,,,fee schedule,,,843.98,,,percent of total billed charges,,,,,,,,,843.98,,,percent of total billed charges,,,517.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,601.34,,,percent of total billed charges,,,,,,,,,,,,,,,455.75,,,percent of total billed charges,,,438.87,,,percent of total billed charges,,,464.19,,,percent of total billed charges,,,,,,,,,497.95,,,percent of total billed charges,,,548.68,,,per diem,,,843.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,843.98,,,percent of total billed charges,,,717.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,448.24,,,percent of total billed charges,,,843.98,,,percent of total billed charges,,,843.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,569.35,,,percent of total billed charges,,,682.95,,,percent of total billed charges,,,,,,,,,,,,,,,337.59,,,percent of total billed charges,,,,,,,,,312.27,,,percent of total billed charges,,,312.27,,,percent of total billed charges,,,,,,,,,843.98,,,percent of total billed charges,,,843.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,843.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,67.52,,,percent of total billed charges,,,843.98,,,percent of total billed charges,,,,,,,,,,,,,,,843.98,,,percent of total billed charges,,,843.98,,,percent of total billed charges,,,,,,,,,785.07,,,percent of total billed charges,,,,,,,,,,,,,,,785.07,,,percent of total billed charges,,,785.07,,,percent of total billed charges,,,785.07,,,percent of total billed charges,,,632.99,,,percent of total billed charges,,,843.98,,,percent of total billed charges,,,843.98,,,percent of total billed charges,,,843.98,,,percent of total billed charges,,,,,,,,,591.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,497.27,,,percent of total billed charges,,
FLUTICSN/SALMT 230/21 HFA 8 GM,2500011366,CDM,637,RC,173071722,NDC,999,EAPG,,,,outpatient,facility,8,UN,843.98,843.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUVOXAMINE MAL 50 MG TAB,2500011385,CDM,637,RC,6255915901,NDC,,,,,,inpatient,facility,50,UN,8.48,8.48,0.68,8.48,,,,,,,,,,,,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.48,,,percent of total billed charges,,,,,,,,,8.48,,,percent of total billed charges,,,4.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.09,,,percent of total billed charges,,,,,,,,,,,,,,,8.48,,,percent of total billed charges,,,7.21,,,percent of total billed charges,,,,,,,,,,,,,,,8.48,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5,,,percent of total billed charges,,
FLUVOXAMINE MAL 50 MG TAB,2500011385,CDM,637,RC,6255915901,NDC,,,,,,outpatient,facility,50,UN,8.48,8.48,0.68,548.68,,6.01,,,percent of total billed charges,,,2.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.48,,,percent of total billed charges,,,5.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.48,,,fee schedule,,,8.48,,,percent of total billed charges,,,,,,,,,8.48,,,percent of total billed charges,,,5.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.04,,,percent of total billed charges,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,4.41,,,percent of total billed charges,,,4.66,,,percent of total billed charges,,,,,,,,,5,,,percent of total billed charges,,,548.68,,,per diem,,,8.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.48,,,percent of total billed charges,,,7.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.5,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.72,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,,,,,,,3.14,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,,,,,,,8.48,,,percent of total billed charges,,,8.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.68,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,8.48,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,,,,,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,7.89,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,6.36,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,,,,,,,5.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5,,,percent of total billed charges,,
FLUVOXAMINE MAL 50 MG TAB,2500011385,CDM,637,RC,6255915901,NDC,999,EAPG,,,,outpatient,facility,50,UN,8.48,8.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FOLIC ACID 5 MG/ML INJ,2500011394,CDM,250,RC,J3490,HCPCS,6332318410,NDC,,,,inpatient,facility,1,UN,18.51,18.51,1.48,18.51,,,,,,,,,,,,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.51,,,percent of total billed charges,,,,,,,,,18.51,,,percent of total billed charges,,,9.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.11,,,percent of total billed charges,,,,,,,,,,,,,,,18.51,,,percent of total billed charges,,,15.73,,,percent of total billed charges,,,,,,,,,,,,,,,18.51,,,percent of total billed charges,,,9.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.91,,,percent of total billed charges,,
FOLIC ACID 5 MG/ML INJ,2500011394,CDM,250,RC,J3490,HCPCS,6332318410,NDC,,,,outpatient,facility,1,UN,18.51,18.51,1.2,548.68,,13.13,,,percent of total billed charges,,,4.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,18.51,,,percent of total billed charges,,,11.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,13.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,13.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.77,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,18.51,,,fee schedule,,,18.51,,,percent of total billed charges,,,,,,,,,18.51,,,percent of total billed charges,,,11.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.19,,,percent of total billed charges,,,,,,,,,,,,,,,18.51,,,percent of total billed charges,,,18.51,,,percent of total billed charges,,,18.51,,,percent of total billed charges,,,,,,,,,10.92,,,percent of total billed charges,,,548.68,,,per diem,,,18.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,18.51,,,percent of total billed charges,,,15.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.83,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,14.98,,,percent of total billed charges,,,,,,,,,,,,,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,18.51,,,percent of total billed charges,,,18.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.48,,,percent of total billed charges,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,,18.51,,,percent of total billed charges,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,13.88,,,percent of total billed charges,,,18.51,,,percent of total billed charges,,,18.51,,,percent of total billed charges,,,18.51,,,percent of total billed charges,,,,,,,,,12.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.26,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.91,,,percent of total billed charges,,
FOLIC ACID 5 MG/ML INJ,2500011394,CDM,250,RC,J3490,HCPCS,6332318410,NDC,435,EAPG,,outpatient,facility,1,UN,18.51,18.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FUROSEMIDE 20 MG TAB,2500011430,CDM,637,RC,5107907220,NDC,,,,,,inpatient,facility,20,UN,0.49,0.49,0.04,0.49,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,
FUROSEMIDE 20 MG TAB,2500011430,CDM,637,RC,5107907220,NDC,,,,,,outpatient,facility,20,UN,0.49,0.49,0.04,548.68,,0.35,,,percent of total billed charges,,,0.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.49,,,percent of total billed charges,,,0.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.49,,,fee schedule,,,0.49,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,548.68,,,per diem,,,0.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.49,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,0.18,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.29,,,percent of total billed charges,,
FUROSEMIDE 20 MG TAB,2500011430,CDM,637,RC,5107907220,NDC,999,EAPG,,,,outpatient,facility,20,UN,0.49,0.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FUROSEMIDE 40 MG TAB,2500011431,CDM,637,RC,5107907320,NDC,,,,,,inpatient,facility,40,UN,0.56,0.56,0.04,0.56,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,
FUROSEMIDE 40 MG TAB,2500011431,CDM,637,RC,5107907320,NDC,,,,,,outpatient,facility,40,UN,0.56,0.56,0.04,548.68,,0.4,,,percent of total billed charges,,,0.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,0.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.2,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.56,,,fee schedule,,,0.56,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,0.33,,,percent of total billed charges,,,548.68,,,per diem,,,0.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.56,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.33,,,percent of total billed charges,,
FUROSEMIDE 40 MG TAB,2500011431,CDM,637,RC,5107907320,NDC,999,EAPG,,,,outpatient,facility,40,UN,0.56,0.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FUROSEMIDE 80 MG TAB,2500011432,CDM,637,RC,5107952720,NDC,,,,,,inpatient,facility,80,UN,1.49,1.49,0.12,1.49,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,1.49,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,
FUROSEMIDE 80 MG TAB,2500011432,CDM,637,RC,5107952720,NDC,,,,,,outpatient,facility,80,UN,1.49,1.49,0.12,548.68,,1.06,,,percent of total billed charges,,,0.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.49,,,percent of total billed charges,,,0.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.55,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.49,,,fee schedule,,,1.49,,,percent of total billed charges,,,,,,,,,1.49,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,0.88,,,percent of total billed charges,,,548.68,,,per diem,,,1.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.49,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,,,,,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,,,,,,,1.49,,,percent of total billed charges,,,1.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.88,,,percent of total billed charges,,
FUROSEMIDE 80 MG TAB,2500011432,CDM,637,RC,5107952720,NDC,999,EAPG,,,,outpatient,facility,80,UN,1.49,1.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GABAPENTIN 100 MG CAP,2500011440,CDM,637,RC,6373959110,NDC,,,,,,inpatient,facility,100,UN,0.29,0.29,0.02,0.29,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,
GABAPENTIN 100 MG CAP,2500011440,CDM,637,RC,6373959110,NDC,,,,,,outpatient,facility,100,UN,0.29,0.29,0.02,548.68,,0.21,,,percent of total billed charges,,,0.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.29,,,percent of total billed charges,,,0.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.29,,,fee schedule,,,0.29,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,0.17,,,percent of total billed charges,,,548.68,,,per diem,,,0.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.29,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,0.11,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.17,,,percent of total billed charges,,
GABAPENTIN 100 MG CAP,2500011440,CDM,637,RC,6373959110,NDC,999,EAPG,,,,outpatient,facility,100,UN,0.29,0.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GABAPENTIN 400 MG CAP,2500011444,CDM,637,RC,904666761,NDC,,,,,,inpatient,facility,400,UN,0.69,0.69,0.06,0.69,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,
GABAPENTIN 400 MG CAP,2500011444,CDM,637,RC,904666761,NDC,,,,,,outpatient,facility,400,UN,0.69,0.69,0.06,548.68,,0.49,,,percent of total billed charges,,,0.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.69,,,percent of total billed charges,,,0.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.69,,,fee schedule,,,0.69,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,0.41,,,percent of total billed charges,,,548.68,,,per diem,,,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.69,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.41,,,percent of total billed charges,,
GABAPENTIN 400 MG CAP,2500011444,CDM,637,RC,904666761,NDC,999,EAPG,,,,outpatient,facility,400,UN,0.69,0.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GABAPENTIN 250 MG  5 ML,2500011448,CDM,637,RC,5038331107,NDC,,,,,,inpatient,facility,5,UN,6.86,6.86,0.55,6.86,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,6.86,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,5.83,,,percent of total billed charges,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,3.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,
GABAPENTIN 250 MG  5 ML,2500011448,CDM,637,RC,5038331107,NDC,,,,,,outpatient,facility,5,UN,6.86,6.86,0.55,548.68,,4.86,,,percent of total billed charges,,,1.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.86,,,percent of total billed charges,,,4.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.51,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.86,,,fee schedule,,,6.86,,,percent of total billed charges,,,,,,,,,6.86,,,percent of total billed charges,,,4.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,3.57,,,percent of total billed charges,,,3.77,,,percent of total billed charges,,,,,,,,,4.05,,,percent of total billed charges,,,548.68,,,per diem,,,6.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.86,,,percent of total billed charges,,,5.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.64,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,5.55,,,percent of total billed charges,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,6.86,,,percent of total billed charges,,,6.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.55,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,6.38,,,percent of total billed charges,,,,,,,,,,,,,,,6.38,,,percent of total billed charges,,,6.38,,,percent of total billed charges,,,6.38,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,4.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.04,,,percent of total billed charges,,
GABAPENTIN 250 MG  5 ML,2500011448,CDM,637,RC,5038331107,NDC,999,EAPG,,,,outpatient,facility,5,UN,6.86,6.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GASTROGRAFIN 30 ML UD,2500011460,CDM,636,RC,Q9963,HCPCS,270044535,NDC,,,,inpatient,facility,30,UN,77.68,77.68,6.21,77.68,,,,,,,,,,,,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.68,,,percent of total billed charges,,,,,,,,,77.68,,,percent of total billed charges,,,39.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.61,,,percent of total billed charges,,,,,,,,,,,,,,,77.68,,,percent of total billed charges,,,66.03,,,percent of total billed charges,,,,,,,,,,,,,,,77.68,,,percent of total billed charges,,,41.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,,6.21,,,percent of total billed charges,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.77,,,percent of total billed charges,,
GASTROGRAFIN 30 ML UD,2500011460,CDM,636,RC,Q9963,HCPCS,270044535,NDC,,,,outpatient,facility,30,UN,77.68,77.68,0.22,548.68,,55.08,,,percent of total billed charges,,,18.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,77.68,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,28.43,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,77.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,77.68,,,fee schedule,,,77.68,,,percent of total billed charges,,,,,,,,,77.68,,,percent of total billed charges,,,47.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,45.83,,,percent of total billed charges,,,548.68,,,per diem,,,77.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,77.68,,,percent of total billed charges,,,66.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.26,,,percent of total billed charges,,,77.68,,,percent of total billed charges,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.4,,,percent of total billed charges,,,62.86,,,percent of total billed charges,,,,,,,,,,,,,,,31.07,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,77.68,,,percent of total billed charges,,,77.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,77.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.21,,,percent of total billed charges,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,,77.68,,,percent of total billed charges,,,77.68,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.22,,,fee schedule,,,77.68,,,percent of total billed charges,,,77.68,,,percent of total billed charges,,,77.68,,,percent of total billed charges,,,,,,,,,54.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,45.77,,,percent of total billed charges,,
GASTROGRAFIN 30 ML UD,2500011460,CDM,636,RC,Q9963,HCPCS,270044535,NDC,999,EAPG,,outpatient,facility,30,UN,77.68,77.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GEMFIBROZIL 600 MG TAB,2500011500,CDM,637,RC,6068722401,NDC,,,,,,inpatient,facility,600,UN,7.66,7.66,0.61,7.66,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,,,,,,,7.66,,,percent of total billed charges,,,3.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,6.51,,,percent of total billed charges,,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,4.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.51,,,percent of total billed charges,,
GEMFIBROZIL 600 MG TAB,2500011500,CDM,637,RC,6068722401,NDC,,,,,,outpatient,facility,600,UN,7.66,7.66,0.61,548.68,,5.43,,,percent of total billed charges,,,1.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.66,,,percent of total billed charges,,,4.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.8,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.66,,,fee schedule,,,7.66,,,percent of total billed charges,,,,,,,,,7.66,,,percent of total billed charges,,,4.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.14,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,,,,,,,4.52,,,percent of total billed charges,,,548.68,,,per diem,,,7.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.66,,,percent of total billed charges,,,6.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.07,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,6.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,,,,,,,2.83,,,percent of total billed charges,,,2.83,,,percent of total billed charges,,,,,,,,,7.66,,,percent of total billed charges,,,7.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.61,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,5.75,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,5.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.51,,,percent of total billed charges,,
GEMFIBROZIL 600 MG TAB,2500011500,CDM,637,RC,6068722401,NDC,999,EAPG,,,,outpatient,facility,600,UN,7.66,7.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENTAMICIN 0.1  OINT 15 GM,2500011522,CDM,637,RC,7120556015,NDC,,,,,,inpatient,facility,15,UN,290.57,290.57,23.25,290.57,,,,,,,,,,,,,,290.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.57,,,percent of total billed charges,,,,,,,,,290.57,,,percent of total billed charges,,,148.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.34,,,percent of total billed charges,,,,,,,,,,,,,,,290.57,,,percent of total billed charges,,,246.98,,,percent of total billed charges,,,,,,,,,,,,,,,290.57,,,percent of total billed charges,,,154.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,290.57,,,percent of total billed charges,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,290.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,290.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.2,,,percent of total billed charges,,
GENTAMICIN 0.1  OINT 15 GM,2500011522,CDM,637,RC,7120556015,NDC,,,,,,outpatient,facility,15,UN,290.57,290.57,23.25,548.68,,206.04,,,percent of total billed charges,,,70.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,290.57,,,percent of total billed charges,,,182.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,204.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,204.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,290.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,106.35,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,290.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,290.57,,,fee schedule,,,290.57,,,percent of total billed charges,,,,,,,,,290.57,,,percent of total billed charges,,,178.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.03,,,percent of total billed charges,,,,,,,,,,,,,,,156.91,,,percent of total billed charges,,,151.1,,,percent of total billed charges,,,159.81,,,percent of total billed charges,,,,,,,,,171.44,,,percent of total billed charges,,,548.68,,,per diem,,,290.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,290.57,,,percent of total billed charges,,,246.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.32,,,percent of total billed charges,,,290.57,,,percent of total billed charges,,,290.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.02,,,percent of total billed charges,,,235.13,,,percent of total billed charges,,,,,,,,,,,,,,,116.23,,,percent of total billed charges,,,,,,,,,107.51,,,percent of total billed charges,,,107.51,,,percent of total billed charges,,,,,,,,,290.57,,,percent of total billed charges,,,290.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,290.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.25,,,percent of total billed charges,,,290.57,,,percent of total billed charges,,,,,,,,,,,,,,,290.57,,,percent of total billed charges,,,290.57,,,percent of total billed charges,,,,,,,,,270.29,,,percent of total billed charges,,,,,,,,,,,,,,,270.29,,,percent of total billed charges,,,270.29,,,percent of total billed charges,,,270.29,,,percent of total billed charges,,,217.93,,,percent of total billed charges,,,290.57,,,percent of total billed charges,,,290.57,,,percent of total billed charges,,,290.57,,,percent of total billed charges,,,,,,,,,203.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,171.2,,,percent of total billed charges,,
GENTAMICIN 0.1  OINT 15 GM,2500011522,CDM,637,RC,7120556015,NDC,999,EAPG,,,,outpatient,facility,15,UN,290.57,290.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GENTAMICIN 0.3  OP SOLN 5 ML,2500011526,CDM,637,RC,6131463305,NDC,,,,,,inpatient,facility,5,UN,71.61,71.61,5.73,71.61,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,,,,,,,71.61,,,percent of total billed charges,,,36.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.97,,,percent of total billed charges,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,60.87,,,percent of total billed charges,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,38.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,,,,,,,,,,,,,5.73,,,percent of total billed charges,,,71.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.19,,,percent of total billed charges,,
GENTAMICIN 0.3  OP SOLN 5 ML,2500011526,CDM,637,RC,6131463305,NDC,,,,,,outpatient,facility,5,UN,71.61,71.61,5.73,548.68,,50.78,,,percent of total billed charges,,,17.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,71.61,,,percent of total billed charges,,,44.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,50.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,50.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,26.21,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,71.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,71.61,,,fee schedule,,,71.61,,,percent of total billed charges,,,,,,,,,71.61,,,percent of total billed charges,,,43.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,38.67,,,percent of total billed charges,,,37.24,,,percent of total billed charges,,,39.39,,,percent of total billed charges,,,,,,,,,42.25,,,percent of total billed charges,,,548.68,,,per diem,,,71.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,71.61,,,percent of total billed charges,,,60.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.03,,,percent of total billed charges,,,71.61,,,percent of total billed charges,,,71.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.31,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,28.64,,,percent of total billed charges,,,,,,,,,26.5,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,,,,,,,71.61,,,percent of total billed charges,,,71.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,71.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.73,,,percent of total billed charges,,,71.61,,,percent of total billed charges,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,71.61,,,percent of total billed charges,,,,,,,,,66.61,,,percent of total billed charges,,,,,,,,,,,,,,,66.61,,,percent of total billed charges,,,66.61,,,percent of total billed charges,,,66.61,,,percent of total billed charges,,,53.71,,,percent of total billed charges,,,71.61,,,percent of total billed charges,,,71.61,,,percent of total billed charges,,,71.61,,,percent of total billed charges,,,,,,,,,50.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,42.19,,,percent of total billed charges,,
GENTAMICIN 0.3  OP SOLN 5 ML,2500011526,CDM,637,RC,6131463305,NDC,999,EAPG,,,,outpatient,facility,5,UN,71.61,71.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLIPIZIDE 5 MG TAB,2500011552,CDM,637,RC,904663761,NDC,,,,,,inpatient,facility,5,UN,1.09,1.09,0.09,1.09,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,
GLIPIZIDE 5 MG TAB,2500011552,CDM,637,RC,904663761,NDC,,,,,,outpatient,facility,5,UN,1.09,1.09,0.09,548.68,,0.77,,,percent of total billed charges,,,0.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.09,,,percent of total billed charges,,,0.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.09,,,fee schedule,,,1.09,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,0.64,,,percent of total billed charges,,,548.68,,,per diem,,,1.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.09,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.64,,,percent of total billed charges,,
GLIPIZIDE 5 MG TAB,2500011552,CDM,637,RC,904663761,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.09,1.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLUCOSE 15 GM TUBE,2500011561,CDM,637,RC,574006915,NDC,,,,,,inpatient,facility,15,UN,2.37,2.37,0.19,2.37,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,2.37,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
GLUCOSE 15 GM TUBE,2500011561,CDM,637,RC,574006915,NDC,,,,,,outpatient,facility,15,UN,2.37,2.37,0.19,548.68,,1.68,,,percent of total billed charges,,,0.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.37,,,percent of total billed charges,,,1.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.37,,,fee schedule,,,2.37,,,percent of total billed charges,,,,,,,,,2.37,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,548.68,,,per diem,,,2.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.37,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,0.88,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,,,,,,,2.37,,,percent of total billed charges,,,2.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.19,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,2.2,,,percent of total billed charges,,,,,,,,,,,,,,,2.2,,,percent of total billed charges,,,2.2,,,percent of total billed charges,,,2.2,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
GLUCOSE 15 GM TUBE,2500011561,CDM,637,RC,574006915,NDC,999,EAPG,,,,outpatient,facility,15,UN,2.37,2.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLYCERIN 120 ML,2500011581,CDM,637,RC,395103128,NDC,,,,,,inpatient,facility,120,UN,6.89,6.89,0.55,6.89,,,,,,,,,,,,,,6.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.89,,,percent of total billed charges,,,,,,,,,6.89,,,percent of total billed charges,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,6.89,,,percent of total billed charges,,,5.86,,,percent of total billed charges,,,,,,,,,,,,,,,6.89,,,percent of total billed charges,,,3.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.89,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,6.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,
GLYCERIN 120 ML,2500011581,CDM,637,RC,395103128,NDC,,,,,,outpatient,facility,120,UN,6.89,6.89,0.55,548.68,,4.89,,,percent of total billed charges,,,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.89,,,percent of total billed charges,,,4.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.52,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.89,,,fee schedule,,,6.89,,,percent of total billed charges,,,,,,,,,6.89,,,percent of total billed charges,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,3.72,,,percent of total billed charges,,,3.58,,,percent of total billed charges,,,3.79,,,percent of total billed charges,,,,,,,,,4.07,,,percent of total billed charges,,,548.68,,,per diem,,,6.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.89,,,percent of total billed charges,,,5.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.66,,,percent of total billed charges,,,6.89,,,percent of total billed charges,,,6.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,5.58,,,percent of total billed charges,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,,,,,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,6.89,,,percent of total billed charges,,,6.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.55,,,percent of total billed charges,,,6.89,,,percent of total billed charges,,,,,,,,,,,,,,,6.89,,,percent of total billed charges,,,6.89,,,percent of total billed charges,,,,,,,,,6.41,,,percent of total billed charges,,,,,,,,,,,,,,,6.41,,,percent of total billed charges,,,6.41,,,percent of total billed charges,,,6.41,,,percent of total billed charges,,,5.17,,,percent of total billed charges,,,6.89,,,percent of total billed charges,,,6.89,,,percent of total billed charges,,,6.89,,,percent of total billed charges,,,,,,,,,4.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.06,,,percent of total billed charges,,
GLYCERIN 120 ML,2500011581,CDM,637,RC,395103128,NDC,999,EAPG,,,,outpatient,facility,120,UN,6.89,6.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLYCERIN PEDIATRIC SUPP,2500011590,CDM,637,RC,132008112,NDC,,,,,,inpatient,facility,1,UN,0.03,0.03,0.01,0.03,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,0.03,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,
GLYCERIN PEDIATRIC SUPP,2500011590,CDM,637,RC,132008112,NDC,,,,,,outpatient,facility,1,UN,0.03,0.03,0.01,548.68,,0.02,,,percent of total billed charges,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.03,,,fee schedule,,,0.03,,,percent of total billed charges,,,,,,,,,0.03,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,0.02,,,percent of total billed charges,,,548.68,,,per diem,,,0.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.03,,,percent of total billed charges,,,0.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.02,,,percent of total billed charges,,
GLYCERIN PEDIATRIC SUPP,2500011590,CDM,637,RC,132008112,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.03,0.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLYCOPYRROLATE 1 MG TAB,2500011593,CDM,637,RC,2315560601,NDC,,,,,,inpatient,facility,1,UN,4.32,4.32,0.35,4.32,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,,,,,,,4.32,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,3.67,,,percent of total billed charges,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,2.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,
GLYCOPYRROLATE 1 MG TAB,2500011593,CDM,637,RC,2315560601,NDC,,,,,,outpatient,facility,1,UN,4.32,4.32,0.35,548.68,,3.06,,,percent of total billed charges,,,1.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.32,,,percent of total billed charges,,,2.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.58,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.32,,,fee schedule,,,4.32,,,percent of total billed charges,,,,,,,,,4.32,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,2.25,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,2.55,,,percent of total billed charges,,,548.68,,,per diem,,,4.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.32,,,percent of total billed charges,,,3.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.29,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,,,,,,,1.6,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,4.32,,,percent of total billed charges,,,4.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.35,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,4.02,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.55,,,percent of total billed charges,,
GLYCOPYRROLATE 1 MG TAB,2500011593,CDM,637,RC,2315560601,NDC,999,EAPG,,,,outpatient,facility,1,UN,4.32,4.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLYCOPYRROLATE 0.2MG/ML2ML INJ,2500011594,CDM,250,RC,J3490,HCPCS,7070016625,NDC,,,,inpatient,facility,2,UN,68.54,68.54,5.48,68.54,,,,,,,,,,,,,,68.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.54,,,percent of total billed charges,,,,,,,,,68.54,,,percent of total billed charges,,,35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.12,,,percent of total billed charges,,,,,,,,,,,,,,,68.54,,,percent of total billed charges,,,58.26,,,percent of total billed charges,,,,,,,,,,,,,,,68.54,,,percent of total billed charges,,,36.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,68.54,,,percent of total billed charges,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.38,,,percent of total billed charges,,
GLYCOPYRROLATE 0.2MG/ML2ML INJ,2500011594,CDM,250,RC,J3490,HCPCS,7070016625,NDC,,,,outpatient,facility,2,UN,68.54,68.54,1.2,548.68,,48.6,,,percent of total billed charges,,,16.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,68.54,,,percent of total billed charges,,,42.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,48.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,48.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,68.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,25.09,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,68.54,,,fee schedule,,,68.54,,,percent of total billed charges,,,,,,,,,68.54,,,percent of total billed charges,,,42.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.83,,,percent of total billed charges,,,,,,,,,,,,,,,68.54,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,40.44,,,percent of total billed charges,,,548.68,,,per diem,,,68.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,68.54,,,percent of total billed charges,,,58.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.4,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.24,,,percent of total billed charges,,,55.46,,,percent of total billed charges,,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,68.54,,,percent of total billed charges,,,68.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,68.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.48,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,,,,,,,68.54,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,51.41,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,68.54,,,percent of total billed charges,,,,,,,,,48.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,40.38,,,percent of total billed charges,,
GLYCOPYRROLATE 0.2MG/ML2ML INJ,2500011594,CDM,250,RC,J3490,HCPCS,7070016625,NDC,435,EAPG,,outpatient,facility,2,UN,68.54,68.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLYCOPYRROLATE 0.2MG/ML INJ,2500011597,CDM,250,RC,517460125,NDC,,,,,,inpatient,facility,1,ML,42.9,42.9,3.43,42.9,,,,,,,,,,,,,,42.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.9,,,percent of total billed charges,,,,,,,,,42.9,,,percent of total billed charges,,,21.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.74,,,percent of total billed charges,,,,,,,,,,,,,,,42.9,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,,,,,,,,,,,,,42.9,,,percent of total billed charges,,,22.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,42.9,,,percent of total billed charges,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,42.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,42.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.28,,,percent of total billed charges,,
GLYCOPYRROLATE 0.2MG/ML INJ,2500011597,CDM,250,RC,517460125,NDC,,,,,,outpatient,facility,1,ML,42.9,42.9,3.43,548.68,,30.42,,,percent of total billed charges,,,10.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,42.9,,,percent of total billed charges,,,26.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,30.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,30.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,42.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,15.7,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,42.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,42.9,,,fee schedule,,,42.9,,,percent of total billed charges,,,,,,,,,42.9,,,percent of total billed charges,,,26.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,25.31,,,percent of total billed charges,,,548.68,,,per diem,,,42.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,42.9,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.78,,,percent of total billed charges,,,42.9,,,percent of total billed charges,,,42.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.94,,,percent of total billed charges,,,34.71,,,percent of total billed charges,,,,,,,,,,,,,,,17.16,,,percent of total billed charges,,,,,,,,,17.16,,,percent of total billed charges,,,17.16,,,percent of total billed charges,,,,,,,,,42.9,,,percent of total billed charges,,,42.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,42.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.43,,,percent of total billed charges,,,42.9,,,percent of total billed charges,,,,,,,,,,,,,,,42.9,,,percent of total billed charges,,,42.9,,,percent of total billed charges,,,,,,,,,17.16,,,percent of total billed charges,,,,,,,,,,,,,,,17.16,,,percent of total billed charges,,,17.16,,,percent of total billed charges,,,17.16,,,percent of total billed charges,,,32.17,,,percent of total billed charges,,,42.9,,,percent of total billed charges,,,42.9,,,percent of total billed charges,,,42.9,,,percent of total billed charges,,,,,,,,,30.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,25.28,,,percent of total billed charges,,
GLYCOPYRROLATE 0.2MG/ML INJ,2500011597,CDM,250,RC,517460125,NDC,999,EAPG,,,,outpatient,facility,1,ML,42.9,42.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GOLYTELY 4000 ML,2500011610,CDM,637,RC,5226810001,NDC,,,,,,inpatient,facility,4000,UN,82.1,82.1,6.57,82.1,,,,,,,,,,,,,,82.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.1,,,percent of total billed charges,,,,,,,,,82.1,,,percent of total billed charges,,,41.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.26,,,percent of total billed charges,,,,,,,,,,,,,,,82.1,,,percent of total billed charges,,,69.78,,,percent of total billed charges,,,,,,,,,,,,,,,82.1,,,percent of total billed charges,,,43.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,82.1,,,percent of total billed charges,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,82.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.37,,,percent of total billed charges,,
GOLYTELY 4000 ML,2500011610,CDM,637,RC,5226810001,NDC,,,,,,outpatient,facility,4000,UN,82.1,82.1,6.57,548.68,,58.22,,,percent of total billed charges,,,20.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,82.1,,,percent of total billed charges,,,51.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,57.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,57.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,82.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,30.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,82.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,82.1,,,fee schedule,,,82.1,,,percent of total billed charges,,,,,,,,,82.1,,,percent of total billed charges,,,50.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.5,,,percent of total billed charges,,,,,,,,,,,,,,,44.33,,,percent of total billed charges,,,42.69,,,percent of total billed charges,,,45.16,,,percent of total billed charges,,,,,,,,,48.44,,,percent of total billed charges,,,548.68,,,per diem,,,82.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,82.1,,,percent of total billed charges,,,69.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.6,,,percent of total billed charges,,,82.1,,,percent of total billed charges,,,82.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.38,,,percent of total billed charges,,,66.44,,,percent of total billed charges,,,,,,,,,,,,,,,32.84,,,percent of total billed charges,,,,,,,,,30.38,,,percent of total billed charges,,,30.38,,,percent of total billed charges,,,,,,,,,82.1,,,percent of total billed charges,,,82.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,82.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.57,,,percent of total billed charges,,,82.1,,,percent of total billed charges,,,,,,,,,,,,,,,82.1,,,percent of total billed charges,,,82.1,,,percent of total billed charges,,,,,,,,,76.37,,,percent of total billed charges,,,,,,,,,,,,,,,76.37,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,61.57,,,percent of total billed charges,,,82.1,,,percent of total billed charges,,,82.1,,,percent of total billed charges,,,82.1,,,percent of total billed charges,,,,,,,,,57.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,48.37,,,percent of total billed charges,,
GOLYTELY 4000 ML,2500011610,CDM,637,RC,5226810001,NDC,999,EAPG,,,,outpatient,facility,4000,UN,82.1,82.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUAIFENESIN/DM LIQ 10 ML UDC,2500011650,CDM,637,RC,121127600,NDC,,,,,,inpatient,facility,10,UN,4.16,4.16,0.33,4.16,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,4.16,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,
GUAIFENESIN/DM LIQ 10 ML UDC,2500011650,CDM,637,RC,121127600,NDC,,,,,,outpatient,facility,10,UN,4.16,4.16,0.33,548.68,,2.95,,,percent of total billed charges,,,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.16,,,percent of total billed charges,,,2.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.52,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.16,,,fee schedule,,,4.16,,,percent of total billed charges,,,,,,,,,4.16,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.96,,,percent of total billed charges,,,,,,,,,,,,,,,2.25,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,2.29,,,percent of total billed charges,,,,,,,,,2.45,,,percent of total billed charges,,,548.68,,,per diem,,,4.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.16,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,1.54,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,,,,,,,4.16,,,percent of total billed charges,,,4.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.33,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,3.12,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,2.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.45,,,percent of total billed charges,,
GUAIFENESIN/DM LIQ 10 ML UDC,2500011650,CDM,637,RC,121127600,NDC,999,EAPG,,,,outpatient,facility,10,UN,4.16,4.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUAIFENESIN 200 MG/10 ML UDC,2500011656,CDM,637,RC,121148800,NDC,,,,,,inpatient,facility,10,UN,2.89,2.89,0.23,2.89,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,2.89,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,
GUAIFENESIN 200 MG/10 ML UDC,2500011656,CDM,637,RC,121148800,NDC,,,,,,outpatient,facility,10,UN,2.89,2.89,0.23,548.68,,2.05,,,percent of total billed charges,,,0.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.89,,,percent of total billed charges,,,1.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.06,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.89,,,fee schedule,,,2.89,,,percent of total billed charges,,,,,,,,,2.89,,,percent of total billed charges,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,1.71,,,percent of total billed charges,,,548.68,,,per diem,,,2.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.89,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,2.89,,,percent of total billed charges,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,1.07,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,2.89,,,percent of total billed charges,,,2.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,2.89,,,percent of total billed charges,,,,,,,,,2.69,,,percent of total billed charges,,,,,,,,,,,,,,,2.69,,,percent of total billed charges,,,2.69,,,percent of total billed charges,,,2.69,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,2.89,,,percent of total billed charges,,,2.89,,,percent of total billed charges,,,2.89,,,percent of total billed charges,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.7,,,percent of total billed charges,,
GUAIFENESIN 200 MG/10 ML UDC,2500011656,CDM,637,RC,121148800,NDC,999,EAPG,,,,outpatient,facility,10,UN,2.89,2.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUAIFENESIN LA 600 MG TAB,2500011658,CDM,637,RC,904671839,NDC,,,,,,inpatient,facility,600,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
GUAIFENESIN LA 600 MG TAB,2500011658,CDM,637,RC,904671839,NDC,,,,,,outpatient,facility,600,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
GUAIFENESIN LA 600 MG TAB,2500011658,CDM,637,RC,904671839,NDC,999,EAPG,,,,outpatient,facility,600,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUAIFENESIN/COD ORAL 5 ML UDC,2500011661,CDM,637,RC,121177500,NDC,,,,,,inpatient,facility,5,UN,2.02,2.02,0.16,2.02,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,2.02,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,
GUAIFENESIN/COD ORAL 5 ML UDC,2500011661,CDM,637,RC,121177500,NDC,,,,,,outpatient,facility,5,UN,2.02,2.02,0.16,548.68,,1.43,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.02,,,percent of total billed charges,,,1.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.02,,,fee schedule,,,2.02,,,percent of total billed charges,,,,,,,,,2.02,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,1.19,,,percent of total billed charges,,,548.68,,,per diem,,,2.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.02,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,,,,,,,0.75,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,2.02,,,percent of total billed charges,,,2.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.19,,,percent of total billed charges,,
GUAIFENESIN/COD ORAL 5 ML UDC,2500011661,CDM,637,RC,121177500,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.02,2.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUANFACINE HCL 1 MG TAB,2500011685,CDM,637,RC,591044401,NDC,,,,,,inpatient,facility,1,UN,2.87,2.87,0.23,2.87,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,2.87,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,
GUANFACINE HCL 1 MG TAB,2500011685,CDM,637,RC,591044401,NDC,,,,,,outpatient,facility,1,UN,2.87,2.87,0.23,548.68,,2.04,,,percent of total billed charges,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.87,,,percent of total billed charges,,,1.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.87,,,fee schedule,,,2.87,,,percent of total billed charges,,,,,,,,,2.87,,,percent of total billed charges,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,1.69,,,percent of total billed charges,,,548.68,,,per diem,,,2.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.87,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,2.32,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,1.06,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,2.87,,,percent of total billed charges,,,2.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.69,,,percent of total billed charges,,
GUANFACINE HCL 1 MG TAB,2500011685,CDM,637,RC,591044401,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.87,2.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HALOPERIDOL 1 MG TAB,2500011701,CDM,637,RC,5107973420,NDC,,,,,,inpatient,facility,1,UN,1.61,1.61,0.13,1.61,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,
HALOPERIDOL 1 MG TAB,2500011701,CDM,637,RC,5107973420,NDC,,,,,,outpatient,facility,1,UN,1.61,1.61,0.13,548.68,,1.14,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.61,,,percent of total billed charges,,,1.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.59,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.61,,,fee schedule,,,1.61,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,548.68,,,per diem,,,1.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.61,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,,,,,,,0.6,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.95,,,percent of total billed charges,,
HALOPERIDOL 1 MG TAB,2500011701,CDM,637,RC,5107973420,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.61,1.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HALOPERIDOL 10 MG TAB,2500011702,CDM,637,RC,904673361,NDC,,,,,,inpatient,facility,10,UN,3.8,3.8,0.3,3.8,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,3.8,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,
HALOPERIDOL 10 MG TAB,2500011702,CDM,637,RC,904673361,NDC,,,,,,outpatient,facility,10,UN,3.8,3.8,0.3,548.68,,2.69,,,percent of total billed charges,,,0.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.8,,,percent of total billed charges,,,2.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.39,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.8,,,fee schedule,,,3.8,,,percent of total billed charges,,,,,,,,,3.8,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,1.98,,,percent of total billed charges,,,2.09,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,548.68,,,per diem,,,3.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.8,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,1.41,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,3.8,,,percent of total billed charges,,,3.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.3,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,2.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.24,,,percent of total billed charges,,
HALOPERIDOL 10 MG TAB,2500011702,CDM,637,RC,904673361,NDC,999,EAPG,,,,outpatient,facility,10,UN,3.8,3.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HALOPERIDOL 5 MG TAB,2500011706,CDM,637,RC,904678261,NDC,,,,,,inpatient,facility,5,UN,2.51,2.51,0.2,2.51,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,2.51,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,
HALOPERIDOL 5 MG TAB,2500011706,CDM,637,RC,904678261,NDC,,,,,,outpatient,facility,5,UN,2.51,2.51,0.2,548.68,,1.78,,,percent of total billed charges,,,0.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.51,,,percent of total billed charges,,,1.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.92,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.51,,,fee schedule,,,2.51,,,percent of total billed charges,,,,,,,,,2.51,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,1.48,,,percent of total billed charges,,,548.68,,,per diem,,,2.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.51,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,0.93,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,2.51,,,percent of total billed charges,,,2.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.48,,,percent of total billed charges,,
HALOPERIDOL 5 MG TAB,2500011706,CDM,637,RC,904678261,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.51,2.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HALOPERIDOL ORAL 10MG/5ML UDC,2500011716,CDM,637,RC,121058105,NDC,,,,,,inpatient,facility,5,UN,13.83,13.83,1.11,13.83,,,,,,,,,,,,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.83,,,percent of total billed charges,,,,,,,,,13.83,,,percent of total billed charges,,,7.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.3,,,percent of total billed charges,,,,,,,,,,,,,,,13.83,,,percent of total billed charges,,,11.76,,,percent of total billed charges,,,,,,,,,,,,,,,13.83,,,percent of total billed charges,,,7.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,
HALOPERIDOL ORAL 10MG/5ML UDC,2500011716,CDM,637,RC,121058105,NDC,,,,,,outpatient,facility,5,UN,13.83,13.83,1.11,548.68,,9.81,,,percent of total billed charges,,,3.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.83,,,percent of total billed charges,,,8.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.06,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.83,,,fee schedule,,,13.83,,,percent of total billed charges,,,,,,,,,13.83,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.85,,,percent of total billed charges,,,,,,,,,,,,,,,7.47,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,7.61,,,percent of total billed charges,,,,,,,,,8.16,,,percent of total billed charges,,,548.68,,,per diem,,,13.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.83,,,percent of total billed charges,,,11.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.35,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.33,,,percent of total billed charges,,,11.19,,,percent of total billed charges,,,,,,,,,,,,,,,5.53,,,percent of total billed charges,,,,,,,,,5.12,,,percent of total billed charges,,,5.12,,,percent of total billed charges,,,,,,,,,13.83,,,percent of total billed charges,,,13.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.11,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,13.83,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,,,,,,,12.86,,,percent of total billed charges,,,,,,,,,,,,,,,12.86,,,percent of total billed charges,,,12.86,,,percent of total billed charges,,,12.86,,,percent of total billed charges,,,10.37,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,13.83,,,percent of total billed charges,,,,,,,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.15,,,percent of total billed charges,,
HALOPERIDOL ORAL 10MG/5ML UDC,2500011716,CDM,637,RC,121058105,NDC,999,EAPG,,,,outpatient,facility,5,UN,13.83,13.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEMORRHOIDAL PREP OINT 60 GM,2500011800,CDM,637,RC,536128806,NDC,,,,,,inpatient,facility,60,UN,3.87,3.87,0.31,3.87,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,,,,,,,3.87,,,percent of total billed charges,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,3.29,,,percent of total billed charges,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,
HEMORRHOIDAL PREP OINT 60 GM,2500011800,CDM,637,RC,536128806,NDC,,,,,,outpatient,facility,60,UN,3.87,3.87,0.31,548.68,,2.74,,,percent of total billed charges,,,0.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.87,,,percent of total billed charges,,,2.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.42,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.87,,,fee schedule,,,3.87,,,percent of total billed charges,,,,,,,,,3.87,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,,,,,,,,,,,,,2.09,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,,,,,,,2.28,,,percent of total billed charges,,,548.68,,,per diem,,,3.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.87,,,percent of total billed charges,,,3.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,1.43,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,3.87,,,percent of total billed charges,,,3.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.31,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,3.6,,,percent of total billed charges,,,,,,,,,,,,,,,3.6,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,2.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.28,,,percent of total billed charges,,
HEMORRHOIDAL PREP OINT 60 GM,2500011800,CDM,637,RC,536128806,NDC,999,EAPG,,,,outpatient,facility,60,UN,3.87,3.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEMORRHOIDAL SUPPOSITORY,2500011805,CDM,637,RC,904697712,NDC,,,,,,inpatient,facility,1,UN,0.99,0.99,0.08,0.99,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
HEMORRHOIDAL SUPPOSITORY,2500011805,CDM,637,RC,904697712,NDC,,,,,,outpatient,facility,1,UN,0.99,0.99,0.08,548.68,,0.7,,,percent of total billed charges,,,0.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.99,,,percent of total billed charges,,,0.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.99,,,fee schedule,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,0.58,,,percent of total billed charges,,,548.68,,,per diem,,,0.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.99,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,0.37,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
HEMORRHOIDAL SUPPOSITORY,2500011805,CDM,637,RC,904697712,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.99,0.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEPATITIS A VAC INJ 1440 ADULT,2500011820,CDM,636,RC,90632,CPT,5816082652,NDC,,,,inpatient,facility,1,UN,260.57,260.57,20.85,260.57,,,,,,,,,,,,,,260.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,260.57,,,percent of total billed charges,,,,,,,,,260.57,,,percent of total billed charges,,,133.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,260.57,,,percent of total billed charges,,,221.48,,,percent of total billed charges,,,,,,,,,,,,,,,260.57,,,percent of total billed charges,,,138.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,260.57,,,percent of total billed charges,,,,,,,,,,,,,,,20.85,,,percent of total billed charges,,,260.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,260.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.53,,,percent of total billed charges,,
HEPATITIS A VAC INJ 1440 ADULT,2500011820,CDM,636,RC,90632,CPT,5816082652,NDC,,,,outpatient,facility,1,UN,260.57,260.57,20.85,548.68,,184.77,,,percent of total billed charges,,,63.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,260.57,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,260.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,95.37,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,51.66,,,fee schedule,,,260.57,,,fee schedule,,,260.57,,,percent of total billed charges,,,,,,,,,260.57,,,percent of total billed charges,,,159.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,153.74,,,percent of total billed charges,,,548.68,,,per diem,,,260.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,260.57,,,percent of total billed charges,,,221.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,138.39,,,percent of total billed charges,,,260.57,,,percent of total billed charges,,,260.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.78,,,percent of total billed charges,,,210.85,,,percent of total billed charges,,,,,,,,,,,,,,,104.23,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,260.57,,,percent of total billed charges,,,260.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,260.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.85,,,percent of total billed charges,,,260.57,,,percent of total billed charges,,,,,,,,,,,,,,,260.57,,,percent of total billed charges,,,260.57,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,73.04,,,fee schedule,,,260.57,,,percent of total billed charges,,,260.57,,,percent of total billed charges,,,260.57,,,percent of total billed charges,,,,,,,,,182.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,,,,,,service not payable
HEPATITIS A VAC INJ 1440 ADULT,2500011820,CDM,636,RC,90632,CPT,5816082652,NDC,414,EAPG,,outpatient,facility,1,UN,260.57,260.57,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEPATITIS B IMMUNE GLOB 5 ML,2500011831,CDM,636,RC,90371,CPT,6980042031,NDC,,,,inpatient,facility,5,ML,2411.67,2411.67,192.93,2411.67,,,,,,,,,,,,,,2411.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2411.67,,,percent of total billed charges,,,,,,,,,2411.67,,,percent of total billed charges,,,1231.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2054.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1447,,,percent of total billed charges,,,,,,,,,,,,,,,2411.67,,,percent of total billed charges,,,2049.92,,,percent of total billed charges,,,,,,,,,,,,,,,2411.67,,,percent of total billed charges,,,1280.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,964.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2411.67,,,percent of total billed charges,,,,,,,,,,,,,,,192.93,,,percent of total billed charges,,,2411.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2411.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1420.96,,,percent of total billed charges,,
HEPATITIS B IMMUNE GLOB 5 ML,2500011831,CDM,636,RC,90371,CPT,6980042031,NDC,,,,outpatient,facility,5,ML,2411.67,2411.67,92.74,2411.67,,1710.12,,,percent of total billed charges,,,,,,,,,2411.67,,,percent of total billed charges,,,186.61,,,fee schedule,,,176.55,,,fee schedule,,,,,,,,,176.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2411.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,131.56,,,fee schedule,,,2411.67,,,fee schedule,,,2411.67,,,percent of total billed charges,,,,,,,,,2411.67,,,percent of total billed charges,,,1478.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1718.31,,,percent of total billed charges,,,,,,,,,,,,,,,137.89,,,fee schedule,,,137.89,,,fee schedule,,,137.89,,,fee schedule,,,,,,,,,1422.89,,,percent of total billed charges,,,548.68,,,per diem,,,2411.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2411.67,,,percent of total billed charges,,,2049.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1280.84,,,percent of total billed charges,,,2411.67,,,percent of total billed charges,,,2411.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1626.91,,,percent of total billed charges,,,1951.52,,,percent of total billed charges,,,,,,,,,,,,,,,964.67,,,percent of total billed charges,,,,,,,,,333.86,,,fee schedule,,,240.24,,,fee schedule,,,,,,,,,2411.67,,,percent of total billed charges,,,,,,,,,,,,,,,192.93,,,percent of total billed charges,,,2411.67,,,percent of total billed charges,,,,,,,,,,,,,,,2411.67,,,percent of total billed charges,,,2411.67,,,percent of total billed charges,,,,,,,,,142.67,,,fee schedule,,,,,,,,,,,,,,,123.66,,,fee schedule,,,164.88,,,fee schedule,,,92.74,,,fee schedule,,,149.19,,,fee schedule,,,2411.67,,,percent of total billed charges,,,2411.67,,,percent of total billed charges,,,2411.67,,,percent of total billed charges,,,,,,,,,1690.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1205.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,,,,,,service not payable
HEPATITIS B IMMUNE GLOB 5 ML,2500011831,CDM,636,RC,90371,CPT,6980042031,NDC,1630,APC,,outpatient,facility,5,ML,2411.67,2411.67,140.46,882.67,,,,,,,,150.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,146.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.77,,,fee schedule,,,,,,,,,882.67,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,146.31,,,fee schedule,,,,,,,,,,,,,,,153.63,,,fee schedule,,,153.63,,,fee schedule,,,,,,,,,146.31,,,fee schedule,,,146.31,,,fee schedule,,,153.63,,,fee schedule,,,,,,,,,,,,,,,219.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,146.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.46,,,fee schedule,,,156.55,,,fee schedule,,,153.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.31,,,fee schedule,,,146.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,152.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,146.31,,,fee schedule,,,,,,,,,182.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,182.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,146.31,,,fee schedule,,,146.31,,,fee schedule,,,,,,,,,,,,,,,146.31,,,fee schedule,,,,,,,,,146.31,,,fee schedule,,,150.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.31,,,fee schedule,,,,,,,,,,,,,,,152.16,,,fee schedule,,,146.31,,,fee schedule,,,,,,,,,146.31,,,fee schedule,,,,,,,,,146.31,,,fee schedule,,,153.63,,,fee schedule,,,,,,,,
HEPATITIS B IMMUNE GLOB 5 ML,2500011831,CDM,636,RC,90371,CPT,6980042031,NDC,444,EAPG,,outpatient,facility,5,ML,2411.67,2411.67,1304.36,1969.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1969.58,,,fee schedule,,,1304.36,,,fee schedule,,,1750.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEP B VIR VAC 10MCG/0.5ML VIAL,2500011834,CDM,636,RC,90744,CPT,5816082052,NDC,,,,inpatient,facility,0.5,UN,87.81,87.81,7.02,87.81,,,,,,,,,,,,,,87.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.81,,,percent of total billed charges,,,,,,,,,87.81,,,percent of total billed charges,,,44.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.69,,,percent of total billed charges,,,,,,,,,,,,,,,87.81,,,percent of total billed charges,,,74.64,,,percent of total billed charges,,,,,,,,,,,,,,,87.81,,,percent of total billed charges,,,46.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,87.81,,,percent of total billed charges,,,,,,,,,,,,,,,7.02,,,percent of total billed charges,,,87.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,87.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.74,,,percent of total billed charges,,
HEP B VIR VAC 10MCG/0.5ML VIAL,2500011834,CDM,636,RC,90744,CPT,5816082052,NDC,,,,outpatient,facility,0.5,UN,87.81,87.81,7.02,548.68,,62.27,,,percent of total billed charges,,,16.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,87.81,,,percent of total billed charges,,,39.94,,,fee schedule,,,37.79,,,fee schedule,,,16.35,,,fee schedule,,,37.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,87.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.51,,,fee schedule,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,32.14,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,27.6,,,fee schedule,,,30.77,,,fee schedule,,,87.81,,,percent of total billed charges,,,16.35,,,fee schedule,,,87.81,,,percent of total billed charges,,,53.82,,,percent of total billed charges,,,17.17,,,fee schedule,,,17.17,,,fee schedule,,,,,,,,,16.68,,,fee schedule,,,16.35,,,fee schedule,,,17.17,,,fee schedule,,,62.56,,,percent of total billed charges,,,,,,,,,24.53,,,fee schedule,,,30.77,,,fee schedule,,,30.77,,,fee schedule,,,30.77,,,fee schedule,,,16.84,,,fee schedule,,,51.81,,,percent of total billed charges,,,548.68,,,per diem,,,87.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,87.81,,,percent of total billed charges,,,74.64,,,percent of total billed charges,,,15.78,,,fee schedule,,,17.49,,,fee schedule,,,17.51,,,fee schedule,,,46.64,,,percent of total billed charges,,,87.81,,,percent of total billed charges,,,87.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.35,,,fee schedule,,,16.35,,,fee schedule,,,59.24,,,percent of total billed charges,,,71.06,,,percent of total billed charges,,,,,,,,,17.35,,,fee schedule,,,35.12,,,percent of total billed charges,,,,,,,,,71.35,,,fee schedule,,,51.34,,,fee schedule,,,16.35,,,fee schedule,,,87.81,,,percent of total billed charges,,,20.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.02,,,percent of total billed charges,,,87.81,,,percent of total billed charges,,,16.35,,,fee schedule,,,24.52,,,fee schedule,,,87.81,,,percent of total billed charges,,,87.81,,,percent of total billed charges,,,16.35,,,fee schedule,,,30.49,,,fee schedule,,,16.35,,,fee schedule,,,16.84,,,fee schedule,,,26.43,,,fee schedule,,,35.24,,,fee schedule,,,19.82,,,fee schedule,,,31.93,,,fee schedule,,,87.81,,,percent of total billed charges,,,87.81,,,percent of total billed charges,,,87.81,,,percent of total billed charges,,,43.26,,,fee schedule,,,61.56,,,percent of total billed charges,,,16.35,,,fee schedule,,,17.43,,,fee schedule,,,16.35,,,fee schedule,,,16.35,,,fee schedule,,,16.68,,,fee schedule,,,43.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,16.68,,,fee schedule,,,17.17,,,fee schedule,,,,,,,,service not payable
HEP B VIR VAC 10MCG/0.5ML VIAL,2500011834,CDM,636,RC,90744,CPT,5816082052,NDC,999,EAPG,,outpatient,facility,0.5,UN,87.81,87.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDRALAZINE HCL 10 MG TAB,2500011940,CDM,637,RC,904644061,NDC,,,,,,inpatient,facility,10,UN,0.33,0.33,0.03,0.33,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,0.33,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,
HYDRALAZINE HCL 10 MG TAB,2500011940,CDM,637,RC,904644061,NDC,,,,,,outpatient,facility,10,UN,0.33,0.33,0.03,548.68,,0.23,,,percent of total billed charges,,,0.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.33,,,percent of total billed charges,,,0.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.12,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.33,,,fee schedule,,,0.33,,,percent of total billed charges,,,,,,,,,0.33,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,0.19,,,percent of total billed charges,,,548.68,,,per diem,,,0.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.33,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,0.12,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,,,,,,,0.33,,,percent of total billed charges,,,0.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.19,,,percent of total billed charges,,
HYDRALAZINE HCL 10 MG TAB,2500011940,CDM,637,RC,904644061,NDC,999,EAPG,,,,outpatient,facility,10,UN,0.33,0.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDRALAZINE HCL 25 MG TAB,2500011943,CDM,637,RC,904644161,NDC,,,,,,inpatient,facility,25,UN,0.39,0.39,0.03,0.39,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,
HYDRALAZINE HCL 25 MG TAB,2500011943,CDM,637,RC,904644161,NDC,,,,,,outpatient,facility,25,UN,0.39,0.39,0.03,548.68,,0.28,,,percent of total billed charges,,,0.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.39,,,percent of total billed charges,,,0.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.14,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.39,,,fee schedule,,,0.39,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,548.68,,,per diem,,,0.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.39,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,0.14,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.23,,,percent of total billed charges,,
HYDRALAZINE HCL 25 MG TAB,2500011943,CDM,637,RC,904644161,NDC,999,EAPG,,,,outpatient,facility,25,UN,0.39,0.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCHLOROTHIAZIDE 25 MG TAB,2500011962,CDM,637,RC,1672918317,NDC,,,,,,inpatient,facility,25,UN,0.26,0.26,0.02,0.26,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,
HYDROCHLOROTHIAZIDE 25 MG TAB,2500011962,CDM,637,RC,1672918317,NDC,,,,,,outpatient,facility,25,UN,0.26,0.26,0.02,548.68,,0.18,,,percent of total billed charges,,,0.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,0.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.26,,,fee schedule,,,0.26,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,0.15,,,percent of total billed charges,,,548.68,,,per diem,,,0.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.26,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,,,,,,,0.1,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.15,,,percent of total billed charges,,
HYDROCHLOROTHIAZIDE 25 MG TAB,2500011962,CDM,637,RC,1672918317,NDC,999,EAPG,,,,outpatient,facility,25,UN,0.26,0.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCORTISONE 0.5  CR 30 GM,2500012000,CDM,637,RC,5167220102,NDC,,,,,,inpatient,facility,30,UN,8.72,8.72,0.7,8.72,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,,,,,,,8.72,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.23,,,percent of total billed charges,,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,7.41,,,percent of total billed charges,,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,4.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.14,,,percent of total billed charges,,
HYDROCORTISONE 0.5  CR 30 GM,2500012000,CDM,637,RC,5167220102,NDC,,,,,,outpatient,facility,30,UN,8.72,8.72,0.7,548.68,,6.18,,,percent of total billed charges,,,2.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.72,,,percent of total billed charges,,,5.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.19,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.72,,,fee schedule,,,8.72,,,percent of total billed charges,,,,,,,,,8.72,,,percent of total billed charges,,,5.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.21,,,percent of total billed charges,,,,,,,,,,,,,,,4.71,,,percent of total billed charges,,,4.53,,,percent of total billed charges,,,4.8,,,percent of total billed charges,,,,,,,,,5.14,,,percent of total billed charges,,,548.68,,,per diem,,,8.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.72,,,percent of total billed charges,,,7.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.88,,,percent of total billed charges,,,7.06,,,percent of total billed charges,,,,,,,,,,,,,,,3.49,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,8.72,,,percent of total billed charges,,,8.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.7,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,,,,,,,8.11,,,percent of total billed charges,,,,,,,,,,,,,,,8.11,,,percent of total billed charges,,,8.11,,,percent of total billed charges,,,8.11,,,percent of total billed charges,,,6.54,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,,,,,,,6.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.14,,,percent of total billed charges,,
HYDROCORTISONE 0.5  CR 30 GM,2500012000,CDM,637,RC,5167220102,NDC,999,EAPG,,,,outpatient,facility,30,UN,8.72,8.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCORTISONE 1  CR 30 GM,2500012005,CDM,637,RC,904762331,NDC,,,,,,inpatient,facility,30,UN,5.08,5.08,0.41,5.08,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,,,,,,,5.08,,,percent of total billed charges,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.99,,,percent of total billed charges,,
HYDROCORTISONE 1  CR 30 GM,2500012005,CDM,637,RC,904762331,NDC,,,,,,outpatient,facility,30,UN,5.08,5.08,0.41,548.68,,3.6,,,percent of total billed charges,,,1.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.08,,,percent of total billed charges,,,3.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.86,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.08,,,fee schedule,,,5.08,,,percent of total billed charges,,,,,,,,,5.08,,,percent of total billed charges,,,3.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.62,,,percent of total billed charges,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.79,,,percent of total billed charges,,,,,,,,,3,,,percent of total billed charges,,,548.68,,,per diem,,,5.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.08,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,5.08,,,percent of total billed charges,,,5.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.41,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,,,,,,,4.73,,,percent of total billed charges,,,,,,,,,,,,,,,4.73,,,percent of total billed charges,,,4.73,,,percent of total billed charges,,,4.73,,,percent of total billed charges,,,3.81,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.99,,,percent of total billed charges,,
HYDROCORTISONE 1  CR 30 GM,2500012005,CDM,637,RC,904762331,NDC,999,EAPG,,,,outpatient,facility,30,UN,5.08,5.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCORTISONE 1  OINT 30 GM,2500012007,CDM,637,RC,4580227603,NDC,,,,,,inpatient,facility,30,UN,7.43,7.43,0.59,7.43,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,,,,,,,7.43,,,percent of total billed charges,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,6.32,,,percent of total billed charges,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,3.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.38,,,percent of total billed charges,,
HYDROCORTISONE 1  OINT 30 GM,2500012007,CDM,637,RC,4580227603,NDC,,,,,,outpatient,facility,30,UN,7.43,7.43,0.59,548.68,,5.27,,,percent of total billed charges,,,1.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.43,,,percent of total billed charges,,,4.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.72,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.43,,,fee schedule,,,7.43,,,percent of total billed charges,,,,,,,,,7.43,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.29,,,percent of total billed charges,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,,3.86,,,percent of total billed charges,,,4.09,,,percent of total billed charges,,,,,,,,,4.38,,,percent of total billed charges,,,548.68,,,per diem,,,7.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.43,,,percent of total billed charges,,,6.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.95,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,6.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,2.75,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,,,,,,,7.43,,,percent of total billed charges,,,7.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.59,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,6.91,,,percent of total billed charges,,,,,,,,,,,,,,,6.91,,,percent of total billed charges,,,6.91,,,percent of total billed charges,,,6.91,,,percent of total billed charges,,,5.57,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,,,,,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.38,,,percent of total billed charges,,
HYDROCORTISONE 1  OINT 30 GM,2500012007,CDM,637,RC,4580227603,NDC,999,EAPG,,,,outpatient,facility,30,UN,7.43,7.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCORTISONE 2.5  OINT 30GM,2500012017,CDM,637,RC,168014630,NDC,,,,,,inpatient,facility,30,UN,11.52,11.52,0.92,11.52,,,,,,,,,,,,,,11.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.52,,,percent of total billed charges,,,,,,,,,11.52,,,percent of total billed charges,,,5.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.91,,,percent of total billed charges,,,,,,,,,,,,,,,11.52,,,percent of total billed charges,,,9.79,,,percent of total billed charges,,,,,,,,,,,,,,,11.52,,,percent of total billed charges,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.79,,,percent of total billed charges,,
HYDROCORTISONE 2.5  OINT 30GM,2500012017,CDM,637,RC,168014630,NDC,,,,,,outpatient,facility,30,UN,11.52,11.52,0.92,548.68,,8.17,,,percent of total billed charges,,,2.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,11.52,,,percent of total billed charges,,,7.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,11.52,,,fee schedule,,,11.52,,,percent of total billed charges,,,,,,,,,11.52,,,percent of total billed charges,,,7.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.21,,,percent of total billed charges,,,,,,,,,,,,,,,6.22,,,percent of total billed charges,,,5.99,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,6.8,,,percent of total billed charges,,,548.68,,,per diem,,,11.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11.52,,,percent of total billed charges,,,9.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.77,,,percent of total billed charges,,,9.32,,,percent of total billed charges,,,,,,,,,,,,,,,4.61,,,percent of total billed charges,,,,,,,,,4.26,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,,,,,,,11.52,,,percent of total billed charges,,,11.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.92,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,,,,,,,,,,,,,11.52,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,,,,,,,10.72,,,percent of total billed charges,,,,,,,,,,,,,,,10.72,,,percent of total billed charges,,,10.72,,,percent of total billed charges,,,10.72,,,percent of total billed charges,,,8.64,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,,,,,,,8.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.79,,,percent of total billed charges,,
HYDROCORTISONE 2.5  OINT 30GM,2500012017,CDM,637,RC,168014630,NDC,999,EAPG,,,,outpatient,facility,30,UN,11.52,11.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCORTISONE 10 MG TAB,2500012021,CDM,637,RC,7278909401,NDC,,,,,,inpatient,facility,10,UN,1.61,1.61,0.13,1.61,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,
HYDROCORTISONE 10 MG TAB,2500012021,CDM,637,RC,7278909401,NDC,,,,,,outpatient,facility,10,UN,1.61,1.61,0.13,548.68,,1.14,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.61,,,percent of total billed charges,,,1.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.59,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.61,,,fee schedule,,,1.61,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,548.68,,,per diem,,,1.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.61,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,,,,,,,0.6,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,1.61,,,percent of total billed charges,,,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.95,,,percent of total billed charges,,
HYDROCORTISONE 10 MG TAB,2500012021,CDM,637,RC,7278909401,NDC,999,EAPG,,,,outpatient,facility,10,UN,1.61,1.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCORTISONE 25 MG SUPP,2500012023,CDM,637,RC,713050312,NDC,,,,,,inpatient,facility,25,UN,74.75,74.75,5.98,74.75,,,,,,,,,,,,,,74.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.75,,,percent of total billed charges,,,,,,,,,74.75,,,percent of total billed charges,,,38.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.85,,,percent of total billed charges,,,,,,,,,,,,,,,74.75,,,percent of total billed charges,,,63.54,,,percent of total billed charges,,,,,,,,,,,,,,,74.75,,,percent of total billed charges,,,39.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,74.75,,,percent of total billed charges,,,,,,,,,,,,,,,5.98,,,percent of total billed charges,,,74.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.04,,,percent of total billed charges,,
HYDROCORTISONE 25 MG SUPP,2500012023,CDM,637,RC,713050312,NDC,,,,,,outpatient,facility,25,UN,74.75,74.75,5.98,548.68,,53.01,,,percent of total billed charges,,,18.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,74.75,,,percent of total billed charges,,,46.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,52.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,52.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,74.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,27.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,74.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,74.75,,,fee schedule,,,74.75,,,percent of total billed charges,,,,,,,,,74.75,,,percent of total billed charges,,,45.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.26,,,percent of total billed charges,,,,,,,,,,,,,,,40.37,,,percent of total billed charges,,,38.87,,,percent of total billed charges,,,41.11,,,percent of total billed charges,,,,,,,,,44.1,,,percent of total billed charges,,,548.68,,,per diem,,,74.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,74.75,,,percent of total billed charges,,,63.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.7,,,percent of total billed charges,,,74.75,,,percent of total billed charges,,,74.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.43,,,percent of total billed charges,,,60.49,,,percent of total billed charges,,,,,,,,,,,,,,,29.9,,,percent of total billed charges,,,,,,,,,27.66,,,percent of total billed charges,,,27.66,,,percent of total billed charges,,,,,,,,,74.75,,,percent of total billed charges,,,74.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,74.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.98,,,percent of total billed charges,,,74.75,,,percent of total billed charges,,,,,,,,,,,,,,,74.75,,,percent of total billed charges,,,74.75,,,percent of total billed charges,,,,,,,,,69.53,,,percent of total billed charges,,,,,,,,,,,,,,,69.53,,,percent of total billed charges,,,69.53,,,percent of total billed charges,,,69.53,,,percent of total billed charges,,,56.06,,,percent of total billed charges,,,74.75,,,percent of total billed charges,,,74.75,,,percent of total billed charges,,,74.75,,,percent of total billed charges,,,,,,,,,52.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,44.04,,,percent of total billed charges,,
HYDROCORTISONE 25 MG SUPP,2500012023,CDM,637,RC,713050312,NDC,999,EAPG,,,,outpatient,facility,25,UN,74.75,74.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROCORT/PRAM 1  FOAM 10 GM,2500012056,CDM,637,RC,37682210,NDC,,,,,,inpatient,facility,10,UN,581.79,581.79,46.54,581.79,,,,,,,,,,,,,,581.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,581.79,,,percent of total billed charges,,,,,,,,,581.79,,,percent of total billed charges,,,297.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,495.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.07,,,percent of total billed charges,,,,,,,,,,,,,,,581.79,,,percent of total billed charges,,,494.52,,,percent of total billed charges,,,,,,,,,,,,,,,581.79,,,percent of total billed charges,,,308.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,581.79,,,percent of total billed charges,,,,,,,,,,,,,,,46.54,,,percent of total billed charges,,,581.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,581.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,342.79,,,percent of total billed charges,,
HYDROCORT/PRAM 1  FOAM 10 GM,2500012056,CDM,637,RC,37682210,NDC,,,,,,outpatient,facility,10,UN,581.79,581.79,46.54,581.79,,412.55,,,percent of total billed charges,,,141.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,581.79,,,percent of total billed charges,,,364.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,409,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,409,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,581.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,212.94,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,581.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,581.79,,,fee schedule,,,581.79,,,percent of total billed charges,,,,,,,,,581.79,,,percent of total billed charges,,,356.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,414.53,,,percent of total billed charges,,,,,,,,,,,,,,,314.17,,,percent of total billed charges,,,302.53,,,percent of total billed charges,,,319.98,,,percent of total billed charges,,,,,,,,,343.26,,,percent of total billed charges,,,548.68,,,per diem,,,581.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,581.79,,,percent of total billed charges,,,494.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,308.99,,,percent of total billed charges,,,581.79,,,percent of total billed charges,,,581.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.48,,,percent of total billed charges,,,470.78,,,percent of total billed charges,,,,,,,,,,,,,,,232.72,,,percent of total billed charges,,,,,,,,,215.26,,,percent of total billed charges,,,215.26,,,percent of total billed charges,,,,,,,,,581.79,,,percent of total billed charges,,,581.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,581.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.54,,,percent of total billed charges,,,581.79,,,percent of total billed charges,,,,,,,,,,,,,,,581.79,,,percent of total billed charges,,,581.79,,,percent of total billed charges,,,,,,,,,541.18,,,percent of total billed charges,,,,,,,,,,,,,,,541.18,,,percent of total billed charges,,,541.18,,,percent of total billed charges,,,541.18,,,percent of total billed charges,,,436.34,,,percent of total billed charges,,,581.79,,,percent of total billed charges,,,581.79,,,percent of total billed charges,,,581.79,,,percent of total billed charges,,,,,,,,,407.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,342.79,,,percent of total billed charges,,
HYDROCORT/PRAM 1  FOAM 10 GM,2500012056,CDM,637,RC,37682210,NDC,999,EAPG,,,,outpatient,facility,10,UN,581.79,581.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROGEN PEROXIDE 3  480 ML,2500012060,CDM,637,RC,,,,,,,,inpatient,facility,480,UN,7.2,7.2,0.58,7.2,,,,,,,,,,,,,,7.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.2,,,percent of total billed charges,,,,,,,,,7.2,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,7.2,,,percent of total billed charges,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,7.2,,,percent of total billed charges,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,7.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.24,,,percent of total billed charges,,
HYDROGEN PEROXIDE 3  480 ML,2500012060,CDM,637,RC,,,,,,,,outpatient,facility,480,UN,7.2,7.2,0.58,548.68,,5.11,,,percent of total billed charges,,,1.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.2,,,percent of total billed charges,,,4.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.64,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.2,,,fee schedule,,,7.2,,,percent of total billed charges,,,,,,,,,7.2,,,percent of total billed charges,,,4.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.13,,,percent of total billed charges,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,3.74,,,percent of total billed charges,,,3.96,,,percent of total billed charges,,,,,,,,,4.25,,,percent of total billed charges,,,548.68,,,per diem,,,7.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.2,,,percent of total billed charges,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.82,,,percent of total billed charges,,,7.2,,,percent of total billed charges,,,7.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.86,,,percent of total billed charges,,,5.83,,,percent of total billed charges,,,,,,,,,,,,,,,2.88,,,percent of total billed charges,,,,,,,,,2.66,,,percent of total billed charges,,,2.66,,,percent of total billed charges,,,,,,,,,7.2,,,percent of total billed charges,,,7.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.58,,,percent of total billed charges,,,7.2,,,percent of total billed charges,,,,,,,,,,,,,,,7.2,,,percent of total billed charges,,,7.2,,,percent of total billed charges,,,,,,,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,7.2,,,percent of total billed charges,,,7.2,,,percent of total billed charges,,,7.2,,,percent of total billed charges,,,,,,,,,5.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.24,,,percent of total billed charges,,
HYDROGEN PEROXIDE 3  480 ML,2500012060,CDM,637,RC,999,EAPG,,,,,,outpatient,facility,480,UN,7.2,7.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROMORPHONE INJ 200 MG,2500012071,CDM,636,RC,J1171,HCPCS,1747854005,NDC,,,,inpatient,facility,20,UN,113.69,113.69,9.1,113.69,,,,,,,,,,,,,,113.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.69,,,percent of total billed charges,,,,,,,,,113.69,,,percent of total billed charges,,,58.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.21,,,percent of total billed charges,,,,,,,,,,,,,,,113.69,,,percent of total billed charges,,,96.64,,,percent of total billed charges,,,,,,,,,,,,,,,113.69,,,percent of total billed charges,,,60.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,113.69,,,percent of total billed charges,,,,,,,,,,,,,,,9.1,,,percent of total billed charges,,,113.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,
HYDROMORPHONE INJ 200 MG,2500012071,CDM,636,RC,J1171,HCPCS,1747854005,NDC,,,,outpatient,facility,20,UN,113.69,113.69,9.1,548.68,,80.62,,,percent of total billed charges,,,,,,,,,113.69,,,percent of total billed charges,,,71.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,79.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,79.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,113.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,113.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,113.69,,,fee schedule,,,113.69,,,percent of total billed charges,,,,,,,,,113.69,,,percent of total billed charges,,,69.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81,,,percent of total billed charges,,,,,,,,,,,,,,,61.39,,,percent of total billed charges,,,59.12,,,percent of total billed charges,,,62.53,,,percent of total billed charges,,,,,,,,,67.08,,,percent of total billed charges,,,548.68,,,per diem,,,113.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,113.69,,,percent of total billed charges,,,96.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.38,,,percent of total billed charges,,,113.69,,,percent of total billed charges,,,113.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.7,,,percent of total billed charges,,,92,,,percent of total billed charges,,,,,,,,,,,,,,,45.48,,,percent of total billed charges,,,,,,,,,42.07,,,percent of total billed charges,,,42.07,,,percent of total billed charges,,,,,,,,,113.69,,,percent of total billed charges,,,,,,,,,,,,,,,9.1,,,percent of total billed charges,,,113.69,,,percent of total billed charges,,,,,,,,,,,,,,,113.69,,,percent of total billed charges,,,113.69,,,percent of total billed charges,,,,,,,,,105.75,,,percent of total billed charges,,,,,,,,,,,,,,,105.75,,,percent of total billed charges,,,105.75,,,percent of total billed charges,,,105.75,,,percent of total billed charges,,,85.27,,,percent of total billed charges,,,113.69,,,percent of total billed charges,,,113.69,,,percent of total billed charges,,,113.69,,,percent of total billed charges,,,,,,,,,79.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,66.99,,,percent of total billed charges,,
HYDROMORPHONE INJ 200 MG,2500012071,CDM,636,RC,J1171,HCPCS,1747854005,NDC,791,APC,,outpatient,facility,20,UN,113.69,113.69,0.09,41.61,,,,,,,,0.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,41.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.1,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,
HYDROMORPHONE INJ 200 MG,2500012071,CDM,636,RC,J1171,HCPCS,1747854005,NDC,999,EAPG,,outpatient,facility,20,UN,113.69,113.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROMORPHONE 0.5 MG/0.5ML INJ,2500012076,CDM,636,RC,J1171,HCPCS,409426401,NDC,,,,inpatient,facility,0.5,ML,10.49,10.49,0.84,10.49,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,,,,,,,10.49,,,percent of total billed charges,,,5.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.29,,,percent of total billed charges,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,8.92,,,percent of total billed charges,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,5.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.18,,,percent of total billed charges,,
HYDROMORPHONE 0.5 MG/0.5ML INJ,2500012076,CDM,636,RC,J1171,HCPCS,409426401,NDC,,,,outpatient,facility,0.5,ML,10.49,10.49,0.84,548.68,,7.44,,,percent of total billed charges,,,,,,,,,10.49,,,percent of total billed charges,,,6.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.49,,,fee schedule,,,10.49,,,percent of total billed charges,,,,,,,,,10.49,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,percent of total billed charges,,,,,,,,,,,,,,,5.66,,,percent of total billed charges,,,5.45,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,6.19,,,percent of total billed charges,,,548.68,,,per diem,,,10.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.49,,,percent of total billed charges,,,8.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.08,,,percent of total billed charges,,,8.49,,,percent of total billed charges,,,,,,,,,,,,,,,4.2,,,percent of total billed charges,,,,,,,,,3.88,,,percent of total billed charges,,,3.88,,,percent of total billed charges,,,,,,,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,,,,,,,9.76,,,percent of total billed charges,,,,,,,,,,,,,,,9.76,,,percent of total billed charges,,,9.76,,,percent of total billed charges,,,9.76,,,percent of total billed charges,,,7.87,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,,,,,,,7.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.18,,,percent of total billed charges,,
HYDROMORPHONE 0.5 MG/0.5ML INJ,2500012076,CDM,636,RC,J1171,HCPCS,409426401,NDC,791,APC,,outpatient,facility,0.5,ML,10.49,10.49,0.09,3.84,,,,,,,,0.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,3.84,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.1,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,
HYDROMORPHONE 0.5 MG/0.5ML INJ,2500012076,CDM,636,RC,J1171,HCPCS,409426401,NDC,999,EAPG,,outpatient,facility,0.5,ML,10.49,10.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROXYCHLOROQUINE 200 MG TAB,2500012080,CDM,637,RC,1054457890,NDC,,,,,,inpatient,facility,8,UN,13.49,13.49,1.08,13.49,,,,,,,,,,,,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.49,,,percent of total billed charges,,,,,,,,,13.49,,,percent of total billed charges,,,6.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,13.49,,,percent of total billed charges,,,11.47,,,percent of total billed charges,,,,,,,,,,,,,,,13.49,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,
HYDROXYCHLOROQUINE 200 MG TAB,2500012080,CDM,637,RC,1054457890,NDC,,,,,,outpatient,facility,8,UN,13.49,13.49,1.08,548.68,,9.57,,,percent of total billed charges,,,3.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.49,,,percent of total billed charges,,,8.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.94,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.49,,,fee schedule,,,13.49,,,percent of total billed charges,,,,,,,,,13.49,,,percent of total billed charges,,,8.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.61,,,percent of total billed charges,,,,,,,,,,,,,,,7.28,,,percent of total billed charges,,,7.01,,,percent of total billed charges,,,7.42,,,percent of total billed charges,,,,,,,,,7.96,,,percent of total billed charges,,,548.68,,,per diem,,,13.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.49,,,percent of total billed charges,,,11.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.1,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,5.4,,,percent of total billed charges,,,,,,,,,4.99,,,percent of total billed charges,,,4.99,,,percent of total billed charges,,,,,,,,,13.49,,,percent of total billed charges,,,13.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.08,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,13.49,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,,,,,,,12.55,,,percent of total billed charges,,,,,,,,,,,,,,,12.55,,,percent of total billed charges,,,12.55,,,percent of total billed charges,,,12.55,,,percent of total billed charges,,,10.12,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,,,,,,,9.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.95,,,percent of total billed charges,,
HYDROXYCHLOROQUINE 200 MG TAB,2500012080,CDM,637,RC,1054457890,NDC,999,EAPG,,,,outpatient,facility,8,UN,13.49,13.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROXYPROP MET 2.5  OP 15ML,2500012090,CDM,637,RC,1747806412,NDC,,,,,,inpatient,facility,15,UN,36.3,36.3,2.9,36.3,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,,,,,,,36.3,,,percent of total billed charges,,,18.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.78,,,percent of total billed charges,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,19.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.39,,,percent of total billed charges,,
HYDROXYPROP MET 2.5  OP 15ML,2500012090,CDM,637,RC,1747806412,NDC,,,,,,outpatient,facility,15,UN,36.3,36.3,2.9,548.68,,25.74,,,percent of total billed charges,,,8.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,36.3,,,percent of total billed charges,,,22.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,25.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,25.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,13.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,36.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,36.3,,,fee schedule,,,36.3,,,percent of total billed charges,,,,,,,,,36.3,,,percent of total billed charges,,,22.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.86,,,percent of total billed charges,,,,,,,,,,,,,,,19.6,,,percent of total billed charges,,,18.88,,,percent of total billed charges,,,19.96,,,percent of total billed charges,,,,,,,,,21.42,,,percent of total billed charges,,,548.68,,,per diem,,,36.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,36.3,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.28,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.49,,,percent of total billed charges,,,29.37,,,percent of total billed charges,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,,,,,,,13.43,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,,,,,,,36.3,,,percent of total billed charges,,,36.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,36.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.9,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,,,,,,,33.77,,,percent of total billed charges,,,,,,,,,,,,,,,33.77,,,percent of total billed charges,,,33.77,,,percent of total billed charges,,,33.77,,,percent of total billed charges,,,27.22,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,,,,,,,25.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,21.39,,,percent of total billed charges,,
HYDROXYPROP MET 2.5  OP 15ML,2500012090,CDM,637,RC,1747806412,NDC,999,EAPG,,,,outpatient,facility,15,UN,36.3,36.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROXYUREA 500 MG CAP,2500012110,CDM,637,RC,904693961,NDC,,,,,,inpatient,facility,500,UN,3.2,3.2,0.26,3.2,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,3.2,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,
HYDROXYUREA 500 MG CAP,2500012110,CDM,637,RC,904693961,NDC,,,,,,outpatient,facility,500,UN,3.2,3.2,0.26,548.68,,2.27,,,percent of total billed charges,,,0.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.2,,,percent of total billed charges,,,2.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.17,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.2,,,fee schedule,,,3.2,,,percent of total billed charges,,,,,,,,,3.2,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,1.76,,,percent of total billed charges,,,,,,,,,1.89,,,percent of total billed charges,,,548.68,,,per diem,,,3.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.2,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,3.2,,,percent of total billed charges,,,3.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,2.98,,,percent of total billed charges,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.89,,,percent of total billed charges,,
HYDROXYUREA 500 MG CAP,2500012110,CDM,637,RC,904693961,NDC,999,EAPG,,,,outpatient,facility,500,UN,3.2,3.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROXYZINE 10 MG TAB,2500012120,CDM,637,RC,6808425301,NDC,,,,,,inpatient,facility,10,UN,0.92,0.92,0.07,0.92,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,
HYDROXYZINE 10 MG TAB,2500012120,CDM,637,RC,6808425301,NDC,,,,,,outpatient,facility,10,UN,0.92,0.92,0.07,548.68,,0.65,,,percent of total billed charges,,,0.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.92,,,percent of total billed charges,,,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.34,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.92,,,fee schedule,,,0.92,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,0.54,,,percent of total billed charges,,,548.68,,,per diem,,,0.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.92,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,0.34,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.54,,,percent of total billed charges,,
HYDROXYZINE 10 MG TAB,2500012120,CDM,637,RC,6808425301,NDC,999,EAPG,,,,outpatient,facility,10,UN,0.92,0.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROXYZINE 25 MG TAB,2500012121,CDM,637,RC,904661761,NDC,,,,,,inpatient,facility,25,UN,0.82,0.82,0.07,0.82,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,
HYDROXYZINE 25 MG TAB,2500012121,CDM,637,RC,904661761,NDC,,,,,,outpatient,facility,25,UN,0.82,0.82,0.07,548.68,,0.58,,,percent of total billed charges,,,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.82,,,percent of total billed charges,,,0.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.82,,,fee schedule,,,0.82,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,0.48,,,percent of total billed charges,,,548.68,,,per diem,,,0.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.82,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.48,,,percent of total billed charges,,
HYDROXYZINE 25 MG TAB,2500012121,CDM,637,RC,904661761,NDC,999,EAPG,,,,outpatient,facility,25,UN,0.82,0.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROXYZINE 50 MG TAB,2500012122,CDM,637,RC,904661861,NDC,,,,,,inpatient,facility,50,UN,1.12,1.12,0.09,1.12,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,1.12,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,
HYDROXYZINE 50 MG TAB,2500012122,CDM,637,RC,904661861,NDC,,,,,,outpatient,facility,50,UN,1.12,1.12,0.09,548.68,,0.79,,,percent of total billed charges,,,0.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.12,,,percent of total billed charges,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.41,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.12,,,fee schedule,,,1.12,,,percent of total billed charges,,,,,,,,,1.12,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,548.68,,,per diem,,,1.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.12,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,0.41,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,,,,,,,1.12,,,percent of total billed charges,,,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.66,,,percent of total billed charges,,
HYDROXYZINE 50 MG TAB,2500012122,CDM,637,RC,904661861,NDC,999,EAPG,,,,outpatient,facility,50,UN,1.12,1.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYOSCYAMINE SULF 0.125 MG SL,2500012150,CDM,637,RC,4778101101,NDC,,,,,,inpatient,facility,0.125,UN,2.81,2.81,0.22,2.81,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,2.81,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,
HYOSCYAMINE SULF 0.125 MG SL,2500012150,CDM,637,RC,4778101101,NDC,,,,,,outpatient,facility,0.125,UN,2.81,2.81,0.22,548.68,,1.99,,,percent of total billed charges,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.81,,,percent of total billed charges,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.03,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.81,,,fee schedule,,,2.81,,,percent of total billed charges,,,,,,,,,2.81,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,1.66,,,percent of total billed charges,,,548.68,,,per diem,,,2.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.81,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,2.27,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,1.04,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,2.81,,,percent of total billed charges,,,2.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.22,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.66,,,percent of total billed charges,,
HYOSCYAMINE SULF 0.125 MG SL,2500012150,CDM,637,RC,4778101101,NDC,999,EAPG,,,,outpatient,facility,0.125,UN,2.81,2.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYOSCYAMINE SULF 0.125 MG SOLN,2500012154,CDM,637,RC,5483850615,NDC,,,,,,inpatient,facility,1,UN,8.81,8.81,0.7,8.81,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,8.81,,,percent of total billed charges,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.29,,,percent of total billed charges,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.19,,,percent of total billed charges,,
HYOSCYAMINE SULF 0.125 MG SOLN,2500012154,CDM,637,RC,5483850615,NDC,,,,,,outpatient,facility,1,UN,8.81,8.81,0.7,548.68,,6.25,,,percent of total billed charges,,,2.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.81,,,percent of total billed charges,,,5.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.81,,,fee schedule,,,8.81,,,percent of total billed charges,,,,,,,,,8.81,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.28,,,percent of total billed charges,,,,,,,,,,,,,,,4.76,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,4.85,,,percent of total billed charges,,,,,,,,,5.2,,,percent of total billed charges,,,548.68,,,per diem,,,8.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.81,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,,,,,,,,3.26,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,,,,,,,8.81,,,percent of total billed charges,,,8.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.7,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,8.2,,,percent of total billed charges,,,,,,,,,,,,,,,8.2,,,percent of total billed charges,,,8.2,,,percent of total billed charges,,,8.2,,,percent of total billed charges,,,6.61,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,8.81,,,percent of total billed charges,,,,,,,,,6.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.19,,,percent of total billed charges,,
HYOSCYAMINE SULF 0.125 MG SOLN,2500012154,CDM,637,RC,5483850615,NDC,999,EAPG,,,,outpatient,facility,1,UN,8.81,8.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYPROMELLOSE OPTH 2.5  15 ML,2500012165,CDM,637,RC,1747806412,NDC,,,,,,inpatient,facility,15,UN,36.3,36.3,2.9,36.3,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,,,,,,,36.3,,,percent of total billed charges,,,18.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.78,,,percent of total billed charges,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,19.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.39,,,percent of total billed charges,,
HYPROMELLOSE OPTH 2.5  15 ML,2500012165,CDM,637,RC,1747806412,NDC,,,,,,outpatient,facility,15,UN,36.3,36.3,2.9,548.68,,25.74,,,percent of total billed charges,,,8.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,36.3,,,percent of total billed charges,,,22.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,25.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,25.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,13.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,36.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,36.3,,,fee schedule,,,36.3,,,percent of total billed charges,,,,,,,,,36.3,,,percent of total billed charges,,,22.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.86,,,percent of total billed charges,,,,,,,,,,,,,,,19.6,,,percent of total billed charges,,,18.88,,,percent of total billed charges,,,19.96,,,percent of total billed charges,,,,,,,,,21.42,,,percent of total billed charges,,,548.68,,,per diem,,,36.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,36.3,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.28,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.49,,,percent of total billed charges,,,29.37,,,percent of total billed charges,,,,,,,,,,,,,,,14.52,,,percent of total billed charges,,,,,,,,,13.43,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,,,,,,,36.3,,,percent of total billed charges,,,36.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,36.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.9,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,,,,,,,,,,,,,36.3,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,,,,,,,33.77,,,percent of total billed charges,,,,,,,,,,,,,,,33.77,,,percent of total billed charges,,,33.77,,,percent of total billed charges,,,33.77,,,percent of total billed charges,,,27.22,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,36.3,,,percent of total billed charges,,,,,,,,,25.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,21.39,,,percent of total billed charges,,
HYPROMELLOSE OPTH 2.5  15 ML,2500012165,CDM,637,RC,1747806412,NDC,999,EAPG,,,,outpatient,facility,15,UN,36.3,36.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IBUPROFEN 200 MG TAB,2500012170,CDM,637,RC,904674740,NDC,,,,,,inpatient,facility,200,UN,1.65,1.65,0.13,1.65,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,1.65,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,,percent of total billed charges,,
IBUPROFEN 200 MG TAB,2500012170,CDM,637,RC,904674740,NDC,,,,,,outpatient,facility,200,UN,1.65,1.65,0.13,548.68,,1.17,,,percent of total billed charges,,,0.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.65,,,percent of total billed charges,,,1.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.6,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.65,,,fee schedule,,,1.65,,,percent of total billed charges,,,,,,,,,1.65,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,0.97,,,percent of total billed charges,,,548.68,,,per diem,,,1.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.65,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,0.61,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,,,,,,,1.65,,,percent of total billed charges,,,1.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.97,,,percent of total billed charges,,
IBUPROFEN 200 MG TAB,2500012170,CDM,637,RC,904674740,NDC,999,EAPG,,,,outpatient,facility,200,UN,1.65,1.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IBUPROFEN 400 MG TAB,2500012171,CDM,637,RC,6787731901,NDC,,,,,,inpatient,facility,400,UN,1.22,1.22,0.1,1.22,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,
IBUPROFEN 400 MG TAB,2500012171,CDM,637,RC,6787731901,NDC,,,,,,outpatient,facility,400,UN,1.22,1.22,0.1,548.68,,0.87,,,percent of total billed charges,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.22,,,percent of total billed charges,,,0.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.45,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.22,,,fee schedule,,,1.22,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,0.72,,,percent of total billed charges,,,548.68,,,per diem,,,1.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.22,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,0.45,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.72,,,percent of total billed charges,,
IBUPROFEN 400 MG TAB,2500012171,CDM,637,RC,6787731901,NDC,999,EAPG,,,,outpatient,facility,400,UN,1.22,1.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IBUPROFEN 600 MG TAB,2500012172,CDM,637,RC,904585461,NDC,,,,,,inpatient,facility,600,UN,0.3,0.3,0.02,0.3,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,0.3,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,
IBUPROFEN 600 MG TAB,2500012172,CDM,637,RC,904585461,NDC,,,,,,outpatient,facility,600,UN,0.3,0.3,0.02,548.68,,0.21,,,percent of total billed charges,,,0.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.3,,,percent of total billed charges,,,0.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.3,,,fee schedule,,,0.3,,,percent of total billed charges,,,,,,,,,0.3,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,0.18,,,percent of total billed charges,,,548.68,,,per diem,,,0.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.3,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,0.11,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,0.3,,,percent of total billed charges,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.18,,,percent of total billed charges,,
IBUPROFEN 600 MG TAB,2500012172,CDM,637,RC,904585461,NDC,999,EAPG,,,,outpatient,facility,600,UN,0.3,0.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IBUPROFEN 800 MG TAB,2500012173,CDM,637,RC,904585561,NDC,,,,,,inpatient,facility,800,UN,0.23,0.23,0.02,0.23,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,
IBUPROFEN 800 MG TAB,2500012173,CDM,637,RC,904585561,NDC,,,,,,outpatient,facility,800,UN,0.23,0.23,0.02,548.68,,0.16,,,percent of total billed charges,,,0.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,0.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.23,,,fee schedule,,,0.23,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,0.14,,,percent of total billed charges,,,548.68,,,per diem,,,0.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.23,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,,,,,,,0.09,,,percent of total billed charges,,,0.09,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,0.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.14,,,percent of total billed charges,,
IBUPROFEN 800 MG TAB,2500012173,CDM,637,RC,904585561,NDC,999,EAPG,,,,outpatient,facility,800,UN,0.23,0.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IBUPROFEN 100 MG/5 ML UDC,2500012179,CDM,637,RC,6809449461,NDC,,,,,,inpatient,facility,5,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
IBUPROFEN 100 MG/5 ML UDC,2500012179,CDM,637,RC,6809449461,NDC,,,,,,outpatient,facility,5,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
IBUPROFEN 100 MG/5 ML UDC,2500012179,CDM,637,RC,6809449461,NDC,999,EAPG,,,,outpatient,facility,5,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMIPRAMINE HCL 25 MG TAB,2500012192,CDM,637,RC,4988405501,NDC,,,,,,inpatient,facility,25,UN,2.37,2.37,0.19,2.37,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,2.37,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
IMIPRAMINE HCL 25 MG TAB,2500012192,CDM,637,RC,4988405501,NDC,,,,,,outpatient,facility,25,UN,2.37,2.37,0.19,548.68,,1.68,,,percent of total billed charges,,,0.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.37,,,percent of total billed charges,,,1.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.37,,,fee schedule,,,2.37,,,percent of total billed charges,,,,,,,,,2.37,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,548.68,,,per diem,,,2.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.37,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,0.88,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,,,,,,,2.37,,,percent of total billed charges,,,2.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.19,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,2.2,,,percent of total billed charges,,,,,,,,,,,,,,,2.2,,,percent of total billed charges,,,2.2,,,percent of total billed charges,,,2.2,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
IMIPRAMINE HCL 25 MG TAB,2500012192,CDM,637,RC,4988405501,NDC,999,EAPG,,,,outpatient,facility,25,UN,2.37,2.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INDAPAMIDE 2.5 MG TAB,2500012212,CDM,637,RC,6255951101,NDC,,,,,,inpatient,facility,2.5,UN,5.12,5.12,0.41,5.12,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,,,,,,,5.12,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,5.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.02,,,percent of total billed charges,,
INDAPAMIDE 2.5 MG TAB,2500012212,CDM,637,RC,6255951101,NDC,,,,,,outpatient,facility,2.5,UN,5.12,5.12,0.41,548.68,,3.63,,,percent of total billed charges,,,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.12,,,percent of total billed charges,,,3.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.12,,,fee schedule,,,5.12,,,percent of total billed charges,,,,,,,,,5.12,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.65,,,percent of total billed charges,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,2.66,,,percent of total billed charges,,,2.82,,,percent of total billed charges,,,,,,,,,3.02,,,percent of total billed charges,,,548.68,,,per diem,,,5.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.12,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,,5.12,,,percent of total billed charges,,,5.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.45,,,percent of total billed charges,,,4.14,,,percent of total billed charges,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,1.89,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,,,,,,,5.12,,,percent of total billed charges,,,5.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.41,,,percent of total billed charges,,,5.12,,,percent of total billed charges,,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,5.12,,,percent of total billed charges,,,,,,,,,4.76,,,percent of total billed charges,,,,,,,,,,,,,,,4.76,,,percent of total billed charges,,,4.76,,,percent of total billed charges,,,4.76,,,percent of total billed charges,,,3.84,,,percent of total billed charges,,,5.12,,,percent of total billed charges,,,5.12,,,percent of total billed charges,,,5.12,,,percent of total billed charges,,,,,,,,,3.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.02,,,percent of total billed charges,,
INDAPAMIDE 2.5 MG TAB,2500012212,CDM,637,RC,6255951101,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,5.12,5.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INDOMETHACIN 25 MG CAP,2500012230,CDM,637,RC,7286514801,NDC,,,,,,inpatient,facility,25,UN,1.52,1.52,0.12,1.52,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,
INDOMETHACIN 25 MG CAP,2500012230,CDM,637,RC,7286514801,NDC,,,,,,outpatient,facility,25,UN,1.52,1.52,0.12,548.68,,1.08,,,percent of total billed charges,,,0.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.52,,,percent of total billed charges,,,0.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.52,,,fee schedule,,,1.52,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,0.9,,,percent of total billed charges,,,548.68,,,per diem,,,1.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.52,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,1.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.9,,,percent of total billed charges,,
INDOMETHACIN 25 MG CAP,2500012230,CDM,637,RC,7286514801,NDC,999,EAPG,,,,outpatient,facility,25,UN,1.52,1.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INDOMETHACIN 50 MG SUPP,2500012234,CDM,637,RC,6934410233,NDC,,,,,,inpatient,facility,50,UN,1194.3,1194.3,95.54,1194.3,,,,,,,,,,,,,,1194.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1194.3,,,percent of total billed charges,,,,,,,,,1194.3,,,percent of total billed charges,,,609.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1017.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,716.58,,,percent of total billed charges,,,,,,,,,,,,,,,1194.3,,,percent of total billed charges,,,1015.16,,,percent of total billed charges,,,,,,,,,,,,,,,1194.3,,,percent of total billed charges,,,634.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,477.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1194.3,,,percent of total billed charges,,,,,,,,,,,,,,,95.54,,,percent of total billed charges,,,1194.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1194.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,703.68,,,percent of total billed charges,,
INDOMETHACIN 50 MG SUPP,2500012234,CDM,637,RC,6934410233,NDC,,,,,,outpatient,facility,50,UN,1194.3,1194.3,95.54,1194.3,,846.88,,,percent of total billed charges,,,291.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1194.3,,,percent of total billed charges,,,748.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,839.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,839.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1194.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,437.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1194.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1194.3,,,fee schedule,,,1194.3,,,percent of total billed charges,,,,,,,,,1194.3,,,percent of total billed charges,,,731.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850.94,,,percent of total billed charges,,,,,,,,,,,,,,,644.92,,,percent of total billed charges,,,621.04,,,percent of total billed charges,,,656.87,,,percent of total billed charges,,,,,,,,,704.64,,,percent of total billed charges,,,548.68,,,per diem,,,1194.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1194.3,,,percent of total billed charges,,,1015.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,634.29,,,percent of total billed charges,,,1194.3,,,percent of total billed charges,,,1194.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,805.67,,,percent of total billed charges,,,966.43,,,percent of total billed charges,,,,,,,,,,,,,,,477.72,,,percent of total billed charges,,,,,,,,,441.89,,,percent of total billed charges,,,441.89,,,percent of total billed charges,,,,,,,,,1194.3,,,percent of total billed charges,,,1194.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1194.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,95.54,,,percent of total billed charges,,,1194.3,,,percent of total billed charges,,,,,,,,,,,,,,,1194.3,,,percent of total billed charges,,,1194.3,,,percent of total billed charges,,,,,,,,,1110.94,,,percent of total billed charges,,,,,,,,,,,,,,,1110.94,,,percent of total billed charges,,,1110.94,,,percent of total billed charges,,,1110.94,,,percent of total billed charges,,,895.72,,,percent of total billed charges,,,1194.3,,,percent of total billed charges,,,1194.3,,,percent of total billed charges,,,1194.3,,,percent of total billed charges,,,,,,,,,837.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,597.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,703.68,,,percent of total billed charges,,
INDOMETHACIN 50 MG SUPP,2500012234,CDM,637,RC,6934410233,NDC,999,EAPG,,,,outpatient,facility,50,UN,1194.3,1194.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IPRATROPIUM 0.03  NASAL 30 ML,2500012310,CDM,637,RC,54004544,NDC,,,,,,inpatient,facility,30,UN,368.51,368.51,29.48,368.51,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,,,,,,,368.51,,,percent of total billed charges,,,188.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.11,,,percent of total billed charges,,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,313.23,,,percent of total billed charges,,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,195.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,29.48,,,percent of total billed charges,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.13,,,percent of total billed charges,,
IPRATROPIUM 0.03  NASAL 30 ML,2500012310,CDM,637,RC,54004544,NDC,,,,,,outpatient,facility,30,UN,368.51,368.51,29.48,548.68,,261.31,,,percent of total billed charges,,,89.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,368.51,,,percent of total billed charges,,,230.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,259.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,259.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,134.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,368.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,368.51,,,fee schedule,,,368.51,,,percent of total billed charges,,,,,,,,,368.51,,,percent of total billed charges,,,225.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.56,,,percent of total billed charges,,,,,,,,,,,,,,,199,,,percent of total billed charges,,,191.63,,,percent of total billed charges,,,202.68,,,percent of total billed charges,,,,,,,,,217.42,,,percent of total billed charges,,,548.68,,,per diem,,,368.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,368.51,,,percent of total billed charges,,,313.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,195.72,,,percent of total billed charges,,,368.51,,,percent of total billed charges,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.6,,,percent of total billed charges,,,298.2,,,percent of total billed charges,,,,,,,,,,,,,,,147.4,,,percent of total billed charges,,,,,,,,,136.35,,,percent of total billed charges,,,136.35,,,percent of total billed charges,,,,,,,,,368.51,,,percent of total billed charges,,,368.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,368.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.48,,,percent of total billed charges,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,368.51,,,percent of total billed charges,,,,,,,,,342.79,,,percent of total billed charges,,,,,,,,,,,,,,,342.79,,,percent of total billed charges,,,342.79,,,percent of total billed charges,,,342.79,,,percent of total billed charges,,,276.38,,,percent of total billed charges,,,368.51,,,percent of total billed charges,,,368.51,,,percent of total billed charges,,,368.51,,,percent of total billed charges,,,,,,,,,258.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,217.13,,,percent of total billed charges,,
IPRATROPIUM 0.03  NASAL 30 ML,2500012310,CDM,637,RC,54004544,NDC,999,EAPG,,,,outpatient,facility,30,UN,368.51,368.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ISONIAZID 300 MG TAB,2500012382,CDM,637,RC,555007102,NDC,,,,,,inpatient,facility,300,UN,1.02,1.02,0.08,1.02,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,
ISONIAZID 300 MG TAB,2500012382,CDM,637,RC,555007102,NDC,,,,,,outpatient,facility,300,UN,1.02,1.02,0.08,548.68,,0.72,,,percent of total billed charges,,,0.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.02,,,percent of total billed charges,,,0.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.37,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.02,,,fee schedule,,,1.02,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.6,,,percent of total billed charges,,,548.68,,,per diem,,,1.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.02,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,0.38,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.6,,,percent of total billed charges,,
ISONIAZID 300 MG TAB,2500012382,CDM,637,RC,555007102,NDC,999,EAPG,,,,outpatient,facility,300,UN,1.02,1.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ISOSORBIDE DINITR 10 MG TAB,2500012410,CDM,637,RC,904661961,NDC,,,,,,inpatient,facility,10,UN,2.01,2.01,0.16,2.01,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
ISOSORBIDE DINITR 10 MG TAB,2500012410,CDM,637,RC,904661961,NDC,,,,,,outpatient,facility,10,UN,2.01,2.01,0.16,548.68,,1.43,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.01,,,percent of total billed charges,,,1.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.01,,,fee schedule,,,2.01,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,1.19,,,percent of total billed charges,,,548.68,,,per diem,,,2.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.01,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
ISOSORBIDE DINITR 10 MG TAB,2500012410,CDM,637,RC,904661961,NDC,999,EAPG,,,,outpatient,facility,10,UN,2.01,2.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ISOSORBIDE DINITR 20 MG TAB,2500012411,CDM,637,RC,904662061,NDC,,,,,,inpatient,facility,20,UN,2.34,2.34,0.19,2.34,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,2.34,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,
ISOSORBIDE DINITR 20 MG TAB,2500012411,CDM,637,RC,904662061,NDC,,,,,,outpatient,facility,20,UN,2.34,2.34,0.19,548.68,,1.66,,,percent of total billed charges,,,0.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.34,,,percent of total billed charges,,,1.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.86,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.34,,,fee schedule,,,2.34,,,percent of total billed charges,,,,,,,,,2.34,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,1.38,,,percent of total billed charges,,,548.68,,,per diem,,,2.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.34,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,,,,,,,0.87,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,2.34,,,percent of total billed charges,,,2.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.19,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.38,,,percent of total billed charges,,
ISOSORBIDE DINITR 20 MG TAB,2500012411,CDM,637,RC,904662061,NDC,999,EAPG,,,,outpatient,facility,20,UN,2.34,2.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ISOSORBIDE DINITR 30 MG TAB,2500012412,CDM,637,RC,4988400901,NDC,,,,,,inpatient,facility,30,UN,4.32,4.32,0.35,4.32,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,,,,,,,4.32,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,3.67,,,percent of total billed charges,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,2.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,
ISOSORBIDE DINITR 30 MG TAB,2500012412,CDM,637,RC,4988400901,NDC,,,,,,outpatient,facility,30,UN,4.32,4.32,0.35,548.68,,3.06,,,percent of total billed charges,,,1.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.32,,,percent of total billed charges,,,2.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.58,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.32,,,fee schedule,,,4.32,,,percent of total billed charges,,,,,,,,,4.32,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,2.25,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,2.55,,,percent of total billed charges,,,548.68,,,per diem,,,4.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.32,,,percent of total billed charges,,,3.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.29,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,,,,,,,1.6,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,4.32,,,percent of total billed charges,,,4.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.35,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,4.02,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.55,,,percent of total billed charges,,
ISOSORBIDE DINITR 30 MG TAB,2500012412,CDM,637,RC,4988400901,NDC,999,EAPG,,,,outpatient,facility,30,UN,4.32,4.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ISOSORBIDE DINITR 5 MG TAB,2500012419,CDM,637,RC,143176901,NDC,,,,,,inpatient,facility,5,UN,3.27,3.27,0.26,3.27,,,,,,,,,,,,,,3.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.27,,,percent of total billed charges,,,,,,,,,3.27,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,3.27,,,percent of total billed charges,,,2.78,,,percent of total billed charges,,,,,,,,,,,,,,,3.27,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,
ISOSORBIDE DINITR 5 MG TAB,2500012419,CDM,637,RC,143176901,NDC,,,,,,outpatient,facility,5,UN,3.27,3.27,0.26,548.68,,2.32,,,percent of total billed charges,,,0.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.27,,,percent of total billed charges,,,2.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.2,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.27,,,fee schedule,,,3.27,,,percent of total billed charges,,,,,,,,,3.27,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,,,,,,,1.93,,,percent of total billed charges,,,548.68,,,per diem,,,3.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.27,,,percent of total billed charges,,,2.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,3.27,,,percent of total billed charges,,,3.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,,,,,,,1.21,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,3.27,,,percent of total billed charges,,,3.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.27,,,percent of total billed charges,,,,,,,,,,,,,,,3.27,,,percent of total billed charges,,,3.27,,,percent of total billed charges,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,2.45,,,percent of total billed charges,,,3.27,,,percent of total billed charges,,,3.27,,,percent of total billed charges,,,3.27,,,percent of total billed charges,,,,,,,,,2.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.93,,,percent of total billed charges,,
ISOSORBIDE DINITR 5 MG TAB,2500012419,CDM,637,RC,143176901,NDC,999,EAPG,,,,outpatient,facility,5,UN,3.27,3.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ISOSORBIDE MONONIT 20 MG TAB,2500012421,CDM,637,RC,6217510701,NDC,,,,,,inpatient,facility,20,UN,2.08,2.08,0.17,2.08,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,
ISOSORBIDE MONONIT 20 MG TAB,2500012421,CDM,637,RC,6217510701,NDC,,,,,,outpatient,facility,20,UN,2.08,2.08,0.17,548.68,,1.47,,,percent of total billed charges,,,0.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.08,,,percent of total billed charges,,,1.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.76,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.08,,,fee schedule,,,2.08,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,1.23,,,percent of total billed charges,,,548.68,,,per diem,,,2.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.08,,,percent of total billed charges,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,0.77,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,2.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,1.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.23,,,percent of total billed charges,,
ISOSORBIDE MONONIT 20 MG TAB,2500012421,CDM,637,RC,6217510701,NDC,999,EAPG,,,,outpatient,facility,20,UN,2.08,2.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ISOSORBIDE MONONIT 30 MG TABCR,2500012422,CDM,637,RC,904644961,NDC,,,,,,inpatient,facility,30,UN,1.25,1.25,0.1,1.25,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,
ISOSORBIDE MONONIT 30 MG TABCR,2500012422,CDM,637,RC,904644961,NDC,,,,,,outpatient,facility,30,UN,1.25,1.25,0.1,548.68,,0.89,,,percent of total billed charges,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.25,,,percent of total billed charges,,,0.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.25,,,fee schedule,,,1.25,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,548.68,,,per diem,,,1.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.25,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.74,,,percent of total billed charges,,
ISOSORBIDE MONONIT 30 MG TABCR,2500012422,CDM,637,RC,904644961,NDC,999,EAPG,,,,outpatient,facility,30,UN,1.25,1.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ISOSORBIDE MONONIT 60 MG TABCR,2500012423,CDM,637,RC,904645061,NDC,,,,,,inpatient,facility,60,UN,1.35,1.35,0.11,1.35,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,
ISOSORBIDE MONONIT 60 MG TABCR,2500012423,CDM,637,RC,904645061,NDC,,,,,,outpatient,facility,60,UN,1.35,1.35,0.11,548.68,,0.96,,,percent of total billed charges,,,0.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.35,,,percent of total billed charges,,,0.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.35,,,fee schedule,,,1.35,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,0.8,,,percent of total billed charges,,,548.68,,,per diem,,,1.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.35,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.8,,,percent of total billed charges,,
ISOSORBIDE MONONIT 60 MG TABCR,2500012423,CDM,637,RC,904645061,NDC,999,EAPG,,,,outpatient,facility,60,UN,1.35,1.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETAMINE HCL 200 MG/20 ML INJ,2500012533,CDM,636,RC,J3490,HCPCS,4202311310,NDC,,,,inpatient,facility,20,ML,65.27,65.27,5.22,65.27,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,,,,,,,65.27,,,percent of total billed charges,,,33.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.16,,,percent of total billed charges,,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,55.48,,,percent of total billed charges,,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,34.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,65.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.46,,,percent of total billed charges,,
KETAMINE HCL 200 MG/20 ML INJ,2500012533,CDM,636,RC,J3490,HCPCS,4202311310,NDC,,,,outpatient,facility,20,ML,65.27,65.27,1.2,548.68,,46.28,,,percent of total billed charges,,,15.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,65.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,23.89,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,65.27,,,fee schedule,,,65.27,,,percent of total billed charges,,,,,,,,,65.27,,,percent of total billed charges,,,40,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.5,,,percent of total billed charges,,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,65.27,,,percent of total billed charges,,,65.27,,,percent of total billed charges,,,,,,,,,38.51,,,percent of total billed charges,,,548.68,,,per diem,,,65.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,65.27,,,percent of total billed charges,,,55.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.66,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.03,,,percent of total billed charges,,,52.82,,,percent of total billed charges,,,,,,,,,,,,,,,26.11,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,65.27,,,percent of total billed charges,,,65.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,65.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.22,,,percent of total billed charges,,,65.27,,,percent of total billed charges,,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,65.27,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,48.95,,,percent of total billed charges,,,65.27,,,percent of total billed charges,,,65.27,,,percent of total billed charges,,,65.27,,,percent of total billed charges,,,,,,,,,45.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,38.46,,,percent of total billed charges,,
KETAMINE HCL 200 MG/20 ML INJ,2500012533,CDM,636,RC,J3490,HCPCS,4202311310,NDC,435,EAPG,,outpatient,facility,20,ML,65.27,65.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETAMINE HCL 50 MG/ML INJ,2500012534,CDM,636,RC,J3490,HCPCS,143950810,NDC,,,,inpatient,facility,1,ML,16.67,16.67,1.33,16.67,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,16.67,,,percent of total billed charges,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,14.17,,,percent of total billed charges,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,8.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.82,,,percent of total billed charges,,
KETAMINE HCL 50 MG/ML INJ,2500012534,CDM,636,RC,J3490,HCPCS,143950810,NDC,,,,outpatient,facility,1,ML,16.67,16.67,1.2,548.68,,11.82,,,percent of total billed charges,,,4.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,16.67,,,fee schedule,,,16.67,,,percent of total billed charges,,,,,,,,,16.67,,,percent of total billed charges,,,10.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,9.84,,,percent of total billed charges,,,548.68,,,per diem,,,16.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,16.67,,,percent of total billed charges,,,14.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.85,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,6.67,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,16.67,,,percent of total billed charges,,,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.33,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,12.5,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,16.67,,,percent of total billed charges,,,,,,,,,11.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.82,,,percent of total billed charges,,
KETAMINE HCL 50 MG/ML INJ,2500012534,CDM,636,RC,J3490,HCPCS,143950810,NDC,435,EAPG,,outpatient,facility,1,ML,16.67,16.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETAMINE HCL 500 MG/5 ML INJ,2500012536,CDM,636,RC,J3490,HCPCS,409205105,NDC,,,,inpatient,facility,5,ML,27.42,27.42,2.19,27.42,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,,,,,,,27.42,,,percent of total billed charges,,,14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.45,,,percent of total billed charges,,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,23.31,,,percent of total billed charges,,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,27.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.16,,,percent of total billed charges,,
KETAMINE HCL 500 MG/5 ML INJ,2500012536,CDM,636,RC,J3490,HCPCS,409205105,NDC,,,,outpatient,facility,5,ML,27.42,27.42,1.2,548.68,,19.44,,,percent of total billed charges,,,6.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,27.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.04,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,27.42,,,fee schedule,,,27.42,,,percent of total billed charges,,,,,,,,,27.42,,,percent of total billed charges,,,16.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.54,,,percent of total billed charges,,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,27.42,,,percent of total billed charges,,,27.42,,,percent of total billed charges,,,,,,,,,16.18,,,percent of total billed charges,,,548.68,,,per diem,,,27.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,27.42,,,percent of total billed charges,,,23.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.56,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.5,,,percent of total billed charges,,,22.19,,,percent of total billed charges,,,,,,,,,,,,,,,10.97,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,27.42,,,percent of total billed charges,,,27.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.19,,,percent of total billed charges,,,27.42,,,percent of total billed charges,,,,,,,,,,,,,,,27.42,,,percent of total billed charges,,,27.42,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,20.57,,,percent of total billed charges,,,27.42,,,percent of total billed charges,,,27.42,,,percent of total billed charges,,,27.42,,,percent of total billed charges,,,,,,,,,19.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,16.16,,,percent of total billed charges,,
KETAMINE HCL 500 MG/5 ML INJ,2500012536,CDM,636,RC,J3490,HCPCS,409205105,NDC,435,EAPG,,outpatient,facility,5,ML,27.42,27.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETAMINE 10  MG/ML 5 ML SYR,2500012538,CDM,636,RC,J3490,HCPCS,4202311410,NDC,,,,inpatient,facility,5,UN,56.1,56.1,4.49,56.1,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,,,,,,,56.1,,,percent of total billed charges,,,28.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,47.68,,,percent of total billed charges,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,29.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,4.49,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.05,,,percent of total billed charges,,
KETAMINE 10  MG/ML 5 ML SYR,2500012538,CDM,636,RC,J3490,HCPCS,4202311410,NDC,,,,outpatient,facility,5,UN,56.1,56.1,1.2,548.68,,39.78,,,percent of total billed charges,,,13.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,20.53,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,56.1,,,fee schedule,,,56.1,,,percent of total billed charges,,,,,,,,,56.1,,,percent of total billed charges,,,34.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.97,,,percent of total billed charges,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,,,,,,,33.1,,,percent of total billed charges,,,548.68,,,per diem,,,56.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,56.1,,,percent of total billed charges,,,47.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.79,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.85,,,percent of total billed charges,,,45.4,,,percent of total billed charges,,,,,,,,,,,,,,,22.44,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,56.1,,,percent of total billed charges,,,56.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,56.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.49,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,42.08,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,,,,,,,39.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,33.05,,,percent of total billed charges,,
KETAMINE 10  MG/ML 5 ML SYR,2500012538,CDM,636,RC,J3490,HCPCS,4202311410,NDC,435,EAPG,,outpatient,facility,5,UN,56.1,56.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOCONAZOLE 2  CR 15 GM,2500012540,CDM,637,RC,168009915,NDC,,,,,,inpatient,facility,15,UN,101.97,101.97,8.16,101.97,,,,,,,,,,,,,,101.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.97,,,percent of total billed charges,,,,,,,,,101.97,,,percent of total billed charges,,,52.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.18,,,percent of total billed charges,,,,,,,,,,,,,,,101.97,,,percent of total billed charges,,,86.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,101.97,,,percent of total billed charges,,,,,,,,,,,,,,,8.16,,,percent of total billed charges,,,101.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,101.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.08,,,percent of total billed charges,,
KETOCONAZOLE 2  CR 15 GM,2500012540,CDM,637,RC,168009915,NDC,,,,,,outpatient,facility,15,UN,101.97,101.97,8.16,548.68,,72.31,,,percent of total billed charges,,,24.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,101.97,,,percent of total billed charges,,,63.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,71.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,71.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,101.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,37.32,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,101.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,101.97,,,fee schedule,,,101.97,,,percent of total billed charges,,,,,,,,,101.97,,,percent of total billed charges,,,62.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.65,,,percent of total billed charges,,,,,,,,,,,,,,,55.06,,,percent of total billed charges,,,53.02,,,percent of total billed charges,,,56.08,,,percent of total billed charges,,,,,,,,,60.16,,,percent of total billed charges,,,548.68,,,per diem,,,101.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,101.97,,,percent of total billed charges,,,86.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.16,,,percent of total billed charges,,,101.97,,,percent of total billed charges,,,101.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.79,,,percent of total billed charges,,,82.51,,,percent of total billed charges,,,,,,,,,,,,,,,40.79,,,percent of total billed charges,,,,,,,,,37.73,,,percent of total billed charges,,,37.73,,,percent of total billed charges,,,,,,,,,101.97,,,percent of total billed charges,,,101.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,101.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.16,,,percent of total billed charges,,,101.97,,,percent of total billed charges,,,,,,,,,,,,,,,101.97,,,percent of total billed charges,,,101.97,,,percent of total billed charges,,,,,,,,,94.85,,,percent of total billed charges,,,,,,,,,,,,,,,94.85,,,percent of total billed charges,,,94.85,,,percent of total billed charges,,,94.85,,,percent of total billed charges,,,76.48,,,percent of total billed charges,,,101.97,,,percent of total billed charges,,,101.97,,,percent of total billed charges,,,101.97,,,percent of total billed charges,,,,,,,,,71.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,60.08,,,percent of total billed charges,,
KETOCONAZOLE 2  CR 15 GM,2500012540,CDM,637,RC,168009915,NDC,999,EAPG,,,,outpatient,facility,15,UN,101.97,101.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOCONAZOLE 200 MG TAB,2500012544,CDM,637,RC,3557343302,NDC,,,,,,inpatient,facility,200,UN,12.51,12.51,1,12.51,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,,,,,,,12.51,,,percent of total billed charges,,,6.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.51,,,percent of total billed charges,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,6.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.37,,,percent of total billed charges,,
KETOCONAZOLE 200 MG TAB,2500012544,CDM,637,RC,3557343302,NDC,,,,,,outpatient,facility,200,UN,12.51,12.51,1,548.68,,8.87,,,percent of total billed charges,,,3.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,12.51,,,percent of total billed charges,,,7.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.58,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,12.51,,,fee schedule,,,12.51,,,percent of total billed charges,,,,,,,,,12.51,,,percent of total billed charges,,,7.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,6.76,,,percent of total billed charges,,,6.51,,,percent of total billed charges,,,6.88,,,percent of total billed charges,,,,,,,,,7.38,,,percent of total billed charges,,,548.68,,,per diem,,,12.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12.51,,,percent of total billed charges,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.64,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.44,,,percent of total billed charges,,,10.12,,,percent of total billed charges,,,,,,,,,,,,,,,5,,,percent of total billed charges,,,,,,,,,4.63,,,percent of total billed charges,,,4.63,,,percent of total billed charges,,,,,,,,,12.51,,,percent of total billed charges,,,12.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,12.51,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,,,,,,,11.64,,,percent of total billed charges,,,,,,,,,,,,,,,11.64,,,percent of total billed charges,,,11.64,,,percent of total billed charges,,,11.64,,,percent of total billed charges,,,9.38,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,,,,,,,8.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.37,,,percent of total billed charges,,
KETOCONAZOLE 200 MG TAB,2500012544,CDM,637,RC,3557343302,NDC,999,EAPG,,,,outpatient,facility,200,UN,12.51,12.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOROLAC 0.5  OPH 5 ML,2500012550,CDM,637,RC,6050510031,NDC,,,,,,inpatient,facility,5,UN,352.67,352.67,28.21,352.67,,,,,,,,,,,,,,352.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.67,,,percent of total billed charges,,,,,,,,,352.67,,,percent of total billed charges,,,180.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,300.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.6,,,percent of total billed charges,,,,,,,,,,,,,,,352.67,,,percent of total billed charges,,,299.77,,,percent of total billed charges,,,,,,,,,,,,,,,352.67,,,percent of total billed charges,,,187.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,352.67,,,percent of total billed charges,,,,,,,,,,,,,,,28.21,,,percent of total billed charges,,,352.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,352.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.79,,,percent of total billed charges,,
KETOROLAC 0.5  OPH 5 ML,2500012550,CDM,637,RC,6050510031,NDC,,,,,,outpatient,facility,5,UN,352.67,352.67,28.21,548.68,,250.08,,,percent of total billed charges,,,86.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,352.67,,,percent of total billed charges,,,221.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,247.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,247.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,352.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,129.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,352.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,352.67,,,fee schedule,,,352.67,,,percent of total billed charges,,,,,,,,,352.67,,,percent of total billed charges,,,216.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,251.28,,,percent of total billed charges,,,,,,,,,,,,,,,190.44,,,percent of total billed charges,,,183.39,,,percent of total billed charges,,,193.97,,,percent of total billed charges,,,,,,,,,208.08,,,percent of total billed charges,,,548.68,,,per diem,,,352.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,352.67,,,percent of total billed charges,,,299.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,187.3,,,percent of total billed charges,,,352.67,,,percent of total billed charges,,,352.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.91,,,percent of total billed charges,,,285.38,,,percent of total billed charges,,,,,,,,,,,,,,,141.07,,,percent of total billed charges,,,,,,,,,130.49,,,percent of total billed charges,,,130.49,,,percent of total billed charges,,,,,,,,,352.67,,,percent of total billed charges,,,352.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,352.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.21,,,percent of total billed charges,,,352.67,,,percent of total billed charges,,,,,,,,,,,,,,,352.67,,,percent of total billed charges,,,352.67,,,percent of total billed charges,,,,,,,,,328.05,,,percent of total billed charges,,,,,,,,,,,,,,,328.05,,,percent of total billed charges,,,328.05,,,percent of total billed charges,,,328.05,,,percent of total billed charges,,,264.5,,,percent of total billed charges,,,352.67,,,percent of total billed charges,,,352.67,,,percent of total billed charges,,,352.67,,,percent of total billed charges,,,,,,,,,247.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,207.79,,,percent of total billed charges,,
KETOROLAC 0.5  OPH 5 ML,2500012550,CDM,637,RC,6050510031,NDC,999,EAPG,,,,outpatient,facility,5,UN,352.67,352.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KETOROLAC 10 MG TAB,2500012551,CDM,637,RC,93031401,NDC,,,,,,inpatient,facility,10,UN,7.13,7.13,0.57,7.13,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,7.13,,,percent of total billed charges,,,3.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,6.06,,,percent of total billed charges,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.2,,,percent of total billed charges,,
KETOROLAC 10 MG TAB,2500012551,CDM,637,RC,93031401,NDC,,,,,,outpatient,facility,10,UN,7.13,7.13,0.57,548.68,,5.06,,,percent of total billed charges,,,1.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.13,,,percent of total billed charges,,,4.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.13,,,fee schedule,,,7.13,,,percent of total billed charges,,,,,,,,,7.13,,,percent of total billed charges,,,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,4.21,,,percent of total billed charges,,,548.68,,,per diem,,,7.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.13,,,percent of total billed charges,,,6.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.79,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.81,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,7.13,,,percent of total billed charges,,,7.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.57,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,,,,,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,6.63,,,percent of total billed charges,,,5.35,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,,,,,,,5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.2,,,percent of total billed charges,,
KETOROLAC 10 MG TAB,2500012551,CDM,637,RC,93031401,NDC,999,EAPG,,,,outpatient,facility,10,UN,7.13,7.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LABETALOL HCL 100 MG TAB,2500012560,CDM,637,RC,6838279801,NDC,,,,,,inpatient,facility,100,UN,2.21,2.21,0.18,2.21,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,
LABETALOL HCL 100 MG TAB,2500012560,CDM,637,RC,6838279801,NDC,,,,,,outpatient,facility,100,UN,2.21,2.21,0.18,548.68,,1.57,,,percent of total billed charges,,,0.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.21,,,percent of total billed charges,,,1.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.81,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.21,,,fee schedule,,,2.21,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,1.3,,,percent of total billed charges,,,548.68,,,per diem,,,2.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.21,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,2.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.3,,,percent of total billed charges,,
LABETALOL HCL 100 MG TAB,2500012560,CDM,637,RC,6838279801,NDC,999,EAPG,,,,outpatient,facility,100,UN,2.21,2.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LABETALOL HCL 100 MG/20 ML INJ,2500012561,CDM,250,RC,J3490,HCPCS,4778158629,NDC,,,,inpatient,facility,20,UN,45.38,45.38,3.63,45.38,,,,,,,,,,,,,,45.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.38,,,percent of total billed charges,,,,,,,,,45.38,,,percent of total billed charges,,,23.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.23,,,percent of total billed charges,,,,,,,,,,,,,,,45.38,,,percent of total billed charges,,,38.57,,,percent of total billed charges,,,,,,,,,,,,,,,45.38,,,percent of total billed charges,,,24.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,45.38,,,percent of total billed charges,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,45.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,45.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.74,,,percent of total billed charges,,
LABETALOL HCL 100 MG/20 ML INJ,2500012561,CDM,250,RC,J3490,HCPCS,4778158629,NDC,,,,outpatient,facility,20,UN,45.38,45.38,1.2,548.68,,32.18,,,percent of total billed charges,,,11.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,45.38,,,percent of total billed charges,,,28.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,31.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,31.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,45.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,16.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,45.38,,,fee schedule,,,45.38,,,percent of total billed charges,,,,,,,,,45.38,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.33,,,percent of total billed charges,,,,,,,,,,,,,,,45.38,,,percent of total billed charges,,,45.38,,,percent of total billed charges,,,45.38,,,percent of total billed charges,,,,,,,,,26.77,,,percent of total billed charges,,,548.68,,,per diem,,,45.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,45.38,,,percent of total billed charges,,,38.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.1,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.61,,,percent of total billed charges,,,36.72,,,percent of total billed charges,,,,,,,,,,,,,,,18.15,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,45.38,,,percent of total billed charges,,,45.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,45.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.63,,,percent of total billed charges,,,45.38,,,percent of total billed charges,,,,,,,,,,,,,,,45.38,,,percent of total billed charges,,,45.38,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,34.04,,,percent of total billed charges,,,45.38,,,percent of total billed charges,,,45.38,,,percent of total billed charges,,,45.38,,,percent of total billed charges,,,,,,,,,31.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,26.74,,,percent of total billed charges,,
LABETALOL HCL 100 MG/20 ML INJ,2500012561,CDM,250,RC,J3490,HCPCS,4778158629,NDC,435,EAPG,,outpatient,facility,20,UN,45.38,45.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LABETALOL HCL 20 MG/4 ML SYR,2500012562,CDM,250,RC,J3490,HCPCS,409233934,NDC,,,,inpatient,facility,4,UN,29.96,29.96,2.4,29.96,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,,,,,,,29.96,,,percent of total billed charges,,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.98,,,percent of total billed charges,,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,25.47,,,percent of total billed charges,,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,15.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.65,,,percent of total billed charges,,
LABETALOL HCL 20 MG/4 ML SYR,2500012562,CDM,250,RC,J3490,HCPCS,409233934,NDC,,,,outpatient,facility,4,UN,29.96,29.96,1.2,548.68,,21.24,,,percent of total billed charges,,,7.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,29.96,,,percent of total billed charges,,,18.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,21.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,21.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.97,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,29.96,,,fee schedule,,,29.96,,,percent of total billed charges,,,,,,,,,29.96,,,percent of total billed charges,,,18.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,,,,,,,17.68,,,percent of total billed charges,,,548.68,,,per diem,,,29.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,29.96,,,percent of total billed charges,,,25.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.91,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.21,,,percent of total billed charges,,,24.24,,,percent of total billed charges,,,,,,,,,,,,,,,11.98,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,29.96,,,percent of total billed charges,,,29.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.4,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,,29.96,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,22.47,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,,,,,,,21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.65,,,percent of total billed charges,,
LABETALOL HCL 20 MG/4 ML SYR,2500012562,CDM,250,RC,J3490,HCPCS,409233934,NDC,435,EAPG,,outpatient,facility,4,UN,29.96,29.96,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LABETALOL HCL 200 MG TAB,2500012563,CDM,637,RC,6838279905,NDC,,,,,,inpatient,facility,200,UN,3.56,3.56,0.28,3.56,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,3.56,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.1,,,percent of total billed charges,,
LABETALOL HCL 200 MG TAB,2500012563,CDM,637,RC,6838279905,NDC,,,,,,outpatient,facility,200,UN,3.56,3.56,0.28,548.68,,2.52,,,percent of total billed charges,,,0.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.56,,,percent of total billed charges,,,2.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.56,,,fee schedule,,,3.56,,,percent of total billed charges,,,,,,,,,3.56,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,2.1,,,percent of total billed charges,,,548.68,,,per diem,,,3.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.56,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,2.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,3.56,,,percent of total billed charges,,,3.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.1,,,percent of total billed charges,,
LABETALOL HCL 200 MG TAB,2500012563,CDM,637,RC,6838279905,NDC,999,EAPG,,,,outpatient,facility,200,UN,3.56,3.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LACTIC ACID 12  LOT 225 GM,2500012582,CDM,637,RC,904598426,NDC,,,,,,inpatient,facility,225,UN,9.24,9.24,0.74,9.24,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,,,,,,,9.24,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,
LACTIC ACID 12  LOT 225 GM,2500012582,CDM,637,RC,904598426,NDC,,,,,,outpatient,facility,225,UN,9.24,9.24,0.74,548.68,,6.55,,,percent of total billed charges,,,2.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.24,,,percent of total billed charges,,,5.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.38,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.24,,,fee schedule,,,9.24,,,percent of total billed charges,,,,,,,,,9.24,,,percent of total billed charges,,,5.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.58,,,percent of total billed charges,,,,,,,,,,,,,,,4.99,,,percent of total billed charges,,,4.8,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,,,,,,,5.45,,,percent of total billed charges,,,548.68,,,per diem,,,9.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.24,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,9.24,,,percent of total billed charges,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,7.48,,,percent of total billed charges,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,,,,,,,3.42,,,percent of total billed charges,,,3.42,,,percent of total billed charges,,,,,,,,,9.24,,,percent of total billed charges,,,9.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.74,,,percent of total billed charges,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,9.24,,,percent of total billed charges,,,,,,,,,8.6,,,percent of total billed charges,,,,,,,,,,,,,,,8.6,,,percent of total billed charges,,,8.6,,,percent of total billed charges,,,8.6,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,9.24,,,percent of total billed charges,,,9.24,,,percent of total billed charges,,,9.24,,,percent of total billed charges,,,,,,,,,6.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.44,,,percent of total billed charges,,
LACTIC ACID 12  LOT 225 GM,2500012582,CDM,637,RC,904598426,NDC,999,EAPG,,,,outpatient,facility,225,UN,9.24,9.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LAMOTRIGINE 100 MG TAB,2500012630,CDM,637,RC,904700861,NDC,,,,,,inpatient,facility,100,UN,0.46,0.46,0.04,0.46,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,
LAMOTRIGINE 100 MG TAB,2500012630,CDM,637,RC,904700861,NDC,,,,,,outpatient,facility,100,UN,0.46,0.46,0.04,548.68,,0.33,,,percent of total billed charges,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,0.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.17,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.46,,,fee schedule,,,0.46,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,0.27,,,percent of total billed charges,,,548.68,,,per diem,,,0.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.46,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,0.17,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.27,,,percent of total billed charges,,
LAMOTRIGINE 100 MG TAB,2500012630,CDM,637,RC,904700861,NDC,999,EAPG,,,,outpatient,facility,100,UN,0.46,0.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LAMOTRIGINE 25 MG TAB,2500012632,CDM,637,RC,6586222701,NDC,,,,,,inpatient,facility,25,UN,13.72,13.72,1.1,13.72,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,,,,,,,13.72,,,percent of total billed charges,,,7.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.23,,,percent of total billed charges,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,11.66,,,percent of total billed charges,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.08,,,percent of total billed charges,,
LAMOTRIGINE 25 MG TAB,2500012632,CDM,637,RC,6586222701,NDC,,,,,,outpatient,facility,25,UN,13.72,13.72,1.1,548.68,,9.73,,,percent of total billed charges,,,3.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.72,,,percent of total billed charges,,,8.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.02,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.72,,,fee schedule,,,13.72,,,percent of total billed charges,,,,,,,,,13.72,,,percent of total billed charges,,,8.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,,,,,,,,,,,,,,7.41,,,percent of total billed charges,,,7.13,,,percent of total billed charges,,,7.55,,,percent of total billed charges,,,,,,,,,8.09,,,percent of total billed charges,,,548.68,,,per diem,,,13.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.72,,,percent of total billed charges,,,11.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.26,,,percent of total billed charges,,,11.1,,,percent of total billed charges,,,,,,,,,,,,,,,5.49,,,percent of total billed charges,,,,,,,,,5.08,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,,,,,,,13.72,,,percent of total billed charges,,,13.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.1,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,,,,,,,13.72,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,12.76,,,percent of total billed charges,,,,,,,,,,,,,,,12.76,,,percent of total billed charges,,,12.76,,,percent of total billed charges,,,12.76,,,percent of total billed charges,,,10.29,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,13.72,,,percent of total billed charges,,,,,,,,,9.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.86,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.08,,,percent of total billed charges,,
LAMOTRIGINE 25 MG TAB,2500012632,CDM,637,RC,6586222701,NDC,999,EAPG,,,,outpatient,facility,25,UN,13.72,13.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LATANOPROST 0.005  OPH 2.5ML,2500012660,CDM,637,RC,6131454701,NDC,,,,,,inpatient,facility,2.5,UN,313.5,313.5,25.08,313.5,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,313.5,,,percent of total billed charges,,,160.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.1,,,percent of total billed charges,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,266.47,,,percent of total billed charges,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,166.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,25.08,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.71,,,percent of total billed charges,,
LATANOPROST 0.005  OPH 2.5ML,2500012660,CDM,637,RC,6131454701,NDC,,,,,,outpatient,facility,2.5,UN,313.5,313.5,25.08,548.68,,222.3,,,percent of total billed charges,,,76.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,313.5,,,percent of total billed charges,,,196.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,220.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,220.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,114.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,313.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,313.5,,,fee schedule,,,313.5,,,percent of total billed charges,,,,,,,,,313.5,,,percent of total billed charges,,,192.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.37,,,percent of total billed charges,,,,,,,,,,,,,,,169.29,,,percent of total billed charges,,,163.02,,,percent of total billed charges,,,172.43,,,percent of total billed charges,,,,,,,,,184.96,,,percent of total billed charges,,,548.68,,,per diem,,,313.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,313.5,,,percent of total billed charges,,,266.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,166.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.49,,,percent of total billed charges,,,253.68,,,percent of total billed charges,,,,,,,,,,,,,,,125.4,,,percent of total billed charges,,,,,,,,,116,,,percent of total billed charges,,,116,,,percent of total billed charges,,,,,,,,,313.5,,,percent of total billed charges,,,313.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,313.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.08,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,291.62,,,percent of total billed charges,,,,,,,,,,,,,,,291.62,,,percent of total billed charges,,,291.62,,,percent of total billed charges,,,291.62,,,percent of total billed charges,,,235.13,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,219.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,184.71,,,percent of total billed charges,,
LATANOPROST 0.005  OPH 2.5ML,2500012660,CDM,637,RC,6131454701,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,313.5,313.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEUCOVORIN CALCIUM 5 MG TAB,2500012682,CDM,637,RC,54449625,NDC,,,,,,inpatient,facility,5,UN,6.7,6.7,0.54,6.7,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,,,,,,,6.7,,,percent of total billed charges,,,3.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,5.7,,,percent of total billed charges,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.95,,,percent of total billed charges,,
LEUCOVORIN CALCIUM 5 MG TAB,2500012682,CDM,637,RC,54449625,NDC,,,,,,outpatient,facility,5,UN,6.7,6.7,0.54,548.68,,4.75,,,percent of total billed charges,,,1.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.7,,,percent of total billed charges,,,4.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.45,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.7,,,fee schedule,,,6.7,,,percent of total billed charges,,,,,,,,,6.7,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,3.62,,,percent of total billed charges,,,3.48,,,percent of total billed charges,,,3.69,,,percent of total billed charges,,,,,,,,,3.95,,,percent of total billed charges,,,548.68,,,per diem,,,6.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.7,,,percent of total billed charges,,,5.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.52,,,percent of total billed charges,,,5.42,,,percent of total billed charges,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,,,,,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,6.7,,,percent of total billed charges,,,6.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.54,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,5.03,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,6.7,,,percent of total billed charges,,,,,,,,,4.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.95,,,percent of total billed charges,,
LEUCOVORIN CALCIUM 5 MG TAB,2500012682,CDM,637,RC,54449625,NDC,999,EAPG,,,,outpatient,facility,5,UN,6.7,6.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVETIRACETAM 500 MG TAB,2500012710,CDM,637,RC,904712461,NDC,,,,,,inpatient,facility,500,UN,0.69,0.69,0.06,0.69,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,
LEVETIRACETAM 500 MG TAB,2500012710,CDM,637,RC,904712461,NDC,,,,,,outpatient,facility,500,UN,0.69,0.69,0.06,548.68,,0.49,,,percent of total billed charges,,,0.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.69,,,percent of total billed charges,,,0.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.69,,,fee schedule,,,0.69,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,0.41,,,percent of total billed charges,,,548.68,,,per diem,,,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.69,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.41,,,percent of total billed charges,,
LEVETIRACETAM 500 MG TAB,2500012710,CDM,637,RC,904712461,NDC,999,EAPG,,,,outpatient,facility,500,UN,0.69,0.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVETIRACETAM 250 MG TAB,2500012712,CDM,637,RC,904712361,NDC,,,,,,inpatient,facility,250,UN,0.59,0.59,0.05,0.59,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,
LEVETIRACETAM 250 MG TAB,2500012712,CDM,637,RC,904712361,NDC,,,,,,outpatient,facility,250,UN,0.59,0.59,0.05,548.68,,0.42,,,percent of total billed charges,,,0.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.59,,,percent of total billed charges,,,0.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.59,,,fee schedule,,,0.59,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,0.35,,,percent of total billed charges,,,548.68,,,per diem,,,0.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.59,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,0.22,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.35,,,percent of total billed charges,,
LEVETIRACETAM 250 MG TAB,2500012712,CDM,637,RC,904712361,NDC,999,EAPG,,,,outpatient,facility,250,UN,0.59,0.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVETIRACETAM INJ 500 MG,2500012714,CDM,636,RC,J1953,HCPCS,5515017705,NDC,,,,inpatient,facility,5,ML,49.5,49.5,3.96,49.5,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,25.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,42.08,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,26.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.17,,,percent of total billed charges,,
LEVETIRACETAM INJ 500 MG,2500012714,CDM,636,RC,J1953,HCPCS,5515017705,NDC,,,,outpatient,facility,5,ML,49.5,49.5,0.06,548.68,,35.1,,,percent of total billed charges,,,12.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,49.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,18.12,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,49.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,49.5,,,fee schedule,,,49.5,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,30.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,29.2,,,percent of total billed charges,,,548.68,,,per diem,,,49.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,49.5,,,percent of total billed charges,,,42.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.29,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.39,,,percent of total billed charges,,,40.06,,,percent of total billed charges,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,49.5,,,percent of total billed charges,,,49.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,49.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.96,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.06,,,fee schedule,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,34.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,29.17,,,percent of total billed charges,,
LEVETIRACETAM INJ 500 MG,2500012714,CDM,636,RC,J1953,HCPCS,5515017705,NDC,999,EAPG,,outpatient,facility,5,ML,49.5,49.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVETRCTM 500 MG/5ML UDC ORAL,2500012716,CDM,250,RC,121479940,NDC,,,,,,inpatient,facility,5,ML,30.85,30.85,2.47,30.85,,,,,,,,,,,,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.85,,,percent of total billed charges,,,,,,,,,30.85,,,percent of total billed charges,,,15.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,,30.85,,,percent of total billed charges,,,26.22,,,percent of total billed charges,,,,,,,,,,,,,,,30.85,,,percent of total billed charges,,,16.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,
LEVETRCTM 500 MG/5ML UDC ORAL,2500012716,CDM,250,RC,121479940,NDC,,,,,,outpatient,facility,5,ML,30.85,30.85,2.47,548.68,,21.88,,,percent of total billed charges,,,7.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,30.85,,,percent of total billed charges,,,19.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,21.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,21.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,30.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,30.85,,,fee schedule,,,30.85,,,percent of total billed charges,,,,,,,,,30.85,,,percent of total billed charges,,,18.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,18.2,,,percent of total billed charges,,,548.68,,,per diem,,,30.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,30.85,,,percent of total billed charges,,,26.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.38,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.81,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,,,,,,,,,,,,,12.34,,,percent of total billed charges,,,,,,,,,12.34,,,percent of total billed charges,,,12.34,,,percent of total billed charges,,,,,,,,,30.85,,,percent of total billed charges,,,30.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.47,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,,,,,,,,,,,,,30.85,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,,,,,,,12.34,,,percent of total billed charges,,,,,,,,,,,,,,,12.34,,,percent of total billed charges,,,12.34,,,percent of total billed charges,,,12.34,,,percent of total billed charges,,,23.14,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,30.85,,,percent of total billed charges,,,,,,,,,21.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.18,,,percent of total billed charges,,
LEVETRCTM 500 MG/5ML UDC ORAL,2500012716,CDM,250,RC,121479940,NDC,999,EAPG,,,,outpatient,facility,5,ML,30.85,30.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVETIRACETAM 500 MG/100ML PMX,2500012717,CDM,636,RC,J1953,HCPCS,5515024647,NDC,,,,inpatient,facility,100,ML,109.89,109.89,8.79,109.89,,,,,,,,,,,,,,109.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.89,,,percent of total billed charges,,,,,,,,,109.89,,,percent of total billed charges,,,56.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.93,,,percent of total billed charges,,,,,,,,,,,,,,,109.89,,,percent of total billed charges,,,93.41,,,percent of total billed charges,,,,,,,,,,,,,,,109.89,,,percent of total billed charges,,,58.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,109.89,,,percent of total billed charges,,,,,,,,,,,,,,,8.79,,,percent of total billed charges,,,109.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.75,,,percent of total billed charges,,
LEVETIRACETAM 500 MG/100ML PMX,2500012717,CDM,636,RC,J1953,HCPCS,5515024647,NDC,,,,outpatient,facility,100,ML,109.89,109.89,0.06,548.68,,77.92,,,percent of total billed charges,,,26.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,109.89,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,109.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,40.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,109.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,109.89,,,fee schedule,,,109.89,,,percent of total billed charges,,,,,,,,,109.89,,,percent of total billed charges,,,67.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,64.84,,,percent of total billed charges,,,548.68,,,per diem,,,109.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,109.89,,,percent of total billed charges,,,93.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.36,,,percent of total billed charges,,,109.89,,,percent of total billed charges,,,109.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.13,,,percent of total billed charges,,,88.92,,,percent of total billed charges,,,,,,,,,,,,,,,43.96,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,109.89,,,percent of total billed charges,,,109.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,109.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.79,,,percent of total billed charges,,,109.89,,,percent of total billed charges,,,,,,,,,,,,,,,109.89,,,percent of total billed charges,,,109.89,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.06,,,fee schedule,,,109.89,,,percent of total billed charges,,,109.89,,,percent of total billed charges,,,109.89,,,percent of total billed charges,,,,,,,,,77.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,64.75,,,percent of total billed charges,,
LEVETIRACETAM 500 MG/100ML PMX,2500012717,CDM,636,RC,J1953,HCPCS,5515024647,NDC,999,EAPG,,outpatient,facility,100,ML,109.89,109.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVETIRACTM 1000 MG/100 ML PMX,2500012718,CDM,636,RC,J1953,HCPCS,5515024747,NDC,,,,inpatient,facility,100,ML,178.2,178.2,14.26,178.2,,,,,,,,,,,,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.2,,,percent of total billed charges,,,,,,,,,178.2,,,percent of total billed charges,,,90.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.92,,,percent of total billed charges,,,,,,,,,,,,,,,178.2,,,percent of total billed charges,,,151.47,,,percent of total billed charges,,,,,,,,,,,,,,,178.2,,,percent of total billed charges,,,94.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105,,,percent of total billed charges,,
LEVETIRACTM 1000 MG/100 ML PMX,2500012718,CDM,636,RC,J1953,HCPCS,5515024747,NDC,,,,outpatient,facility,100,ML,178.2,178.2,0.06,548.68,,126.36,,,percent of total billed charges,,,43.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,178.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,65.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,178.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,178.2,,,fee schedule,,,178.2,,,percent of total billed charges,,,,,,,,,178.2,,,percent of total billed charges,,,109.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,105.14,,,percent of total billed charges,,,548.68,,,per diem,,,178.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,178.2,,,percent of total billed charges,,,151.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.64,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.21,,,percent of total billed charges,,,144.2,,,percent of total billed charges,,,,,,,,,,,,,,,71.28,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,178.2,,,percent of total billed charges,,,178.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,178.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.26,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,,178.2,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.06,,,fee schedule,,,178.2,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,,,,,,,124.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,105,,,percent of total billed charges,,
LEVETIRACTM 1000 MG/100 ML PMX,2500012718,CDM,636,RC,J1953,HCPCS,5515024747,NDC,999,EAPG,,outpatient,facility,100,ML,178.2,178.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVETIRACTM 1500 MG/100 ML PMX,2500012719,CDM,636,RC,J1953,HCPCS,5515024847,NDC,,,,inpatient,facility,100,ML,237.6,237.6,19.01,237.6,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,,,,,,,237.6,,,percent of total billed charges,,,121.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.56,,,percent of total billed charges,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,201.96,,,percent of total billed charges,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,126.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,19.01,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.99,,,percent of total billed charges,,
LEVETIRACTM 1500 MG/100 ML PMX,2500012719,CDM,636,RC,J1953,HCPCS,5515024847,NDC,,,,outpatient,facility,100,ML,237.6,237.6,0.06,548.68,,168.48,,,percent of total billed charges,,,57.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,237.6,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,86.96,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,237.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,237.6,,,fee schedule,,,237.6,,,percent of total billed charges,,,,,,,,,237.6,,,percent of total billed charges,,,145.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,140.18,,,percent of total billed charges,,,548.68,,,per diem,,,237.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,237.6,,,percent of total billed charges,,,201.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.19,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.28,,,percent of total billed charges,,,192.27,,,percent of total billed charges,,,,,,,,,,,,,,,95.04,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,237.6,,,percent of total billed charges,,,237.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,237.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.01,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,,237.6,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.06,,,fee schedule,,,237.6,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,237.6,,,percent of total billed charges,,,,,,,,,166.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,139.99,,,percent of total billed charges,,
LEVETIRACTM 1500 MG/100 ML PMX,2500012719,CDM,636,RC,J1953,HCPCS,5515024847,NDC,999,EAPG,,outpatient,facility,100,ML,237.6,237.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOCARNITINE 330 MG TABLET,2500012730,CDM,637,RC,5448214407,NDC,,,,,,inpatient,facility,330,UN,3.92,3.92,0.31,3.92,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,,,,3.92,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,
LEVOCARNITINE 330 MG TABLET,2500012730,CDM,637,RC,5448214407,NDC,,,,,,outpatient,facility,330,UN,3.92,3.92,0.31,548.68,,2.78,,,percent of total billed charges,,,0.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.92,,,percent of total billed charges,,,2.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.43,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.92,,,fee schedule,,,3.92,,,percent of total billed charges,,,,,,,,,3.92,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,548.68,,,per diem,,,3.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.92,,,percent of total billed charges,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,3.92,,,percent of total billed charges,,,3.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.31,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,3.65,,,percent of total billed charges,,,,,,,,,,,,,,,3.65,,,percent of total billed charges,,,3.65,,,percent of total billed charges,,,3.65,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.31,,,percent of total billed charges,,
LEVOCARNITINE 330 MG TABLET,2500012730,CDM,637,RC,5448214407,NDC,999,EAPG,,,,outpatient,facility,330,UN,3.92,3.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOFLOXACIN 250 MG TAB,2500012760,CDM,637,RC,904635161,NDC,,,,,,inpatient,facility,250,UN,0.73,0.73,0.06,0.73,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,0.73,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,
LEVOFLOXACIN 250 MG TAB,2500012760,CDM,637,RC,904635161,NDC,,,,,,outpatient,facility,250,UN,0.73,0.73,0.06,548.68,,0.52,,,percent of total billed charges,,,0.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.73,,,percent of total billed charges,,,0.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.27,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.73,,,fee schedule,,,0.73,,,percent of total billed charges,,,,,,,,,0.73,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,548.68,,,per diem,,,0.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.73,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,0.73,,,percent of total billed charges,,,0.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,0.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.43,,,percent of total billed charges,,
LEVOFLOXACIN 250 MG TAB,2500012760,CDM,637,RC,904635161,NDC,999,EAPG,,,,outpatient,facility,250,UN,0.73,0.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOFLOXACIN 500 MG TAB,2500012762,CDM,637,RC,904635261,NDC,,,,,,inpatient,facility,500,UN,0.79,0.79,0.06,0.79,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,
LEVOFLOXACIN 500 MG TAB,2500012762,CDM,637,RC,904635261,NDC,,,,,,outpatient,facility,500,UN,0.79,0.79,0.06,548.68,,0.56,,,percent of total billed charges,,,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.79,,,percent of total billed charges,,,0.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.79,,,fee schedule,,,0.79,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,0.47,,,percent of total billed charges,,,548.68,,,per diem,,,0.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.79,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.47,,,percent of total billed charges,,
LEVOFLOXACIN 500 MG TAB,2500012762,CDM,637,RC,904635261,NDC,999,EAPG,,,,outpatient,facility,500,UN,0.79,0.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOFLOXACIN 750 MG TAB,2500012763,CDM,637,RC,904635361,NDC,,,,,,inpatient,facility,750,UN,1.45,1.45,0.12,1.45,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,
LEVOFLOXACIN 750 MG TAB,2500012763,CDM,637,RC,904635361,NDC,,,,,,outpatient,facility,750,UN,1.45,1.45,0.12,548.68,,1.03,,,percent of total billed charges,,,0.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.45,,,percent of total billed charges,,,0.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.53,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.45,,,fee schedule,,,1.45,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,0.86,,,percent of total billed charges,,,548.68,,,per diem,,,1.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.45,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,0.54,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,1.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.85,,,percent of total billed charges,,
LEVOFLOXACIN 750 MG TAB,2500012763,CDM,637,RC,904635361,NDC,999,EAPG,,,,outpatient,facility,750,UN,1.45,1.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 0.025 MG TAB,2500012780,CDM,637,RC,6068745301,NDC,,,,,,inpatient,facility,25,UN,1.84,1.84,0.15,1.84,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,1.84,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,
LEVOTHYROXINE 0.025 MG TAB,2500012780,CDM,637,RC,6068745301,NDC,,,,,,outpatient,facility,25,UN,1.84,1.84,0.15,548.68,,1.3,,,percent of total billed charges,,,0.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.84,,,percent of total billed charges,,,1.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.67,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.84,,,fee schedule,,,1.84,,,percent of total billed charges,,,,,,,,,1.84,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,548.68,,,per diem,,,1.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.84,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,1.84,,,percent of total billed charges,,,1.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.08,,,percent of total billed charges,,
LEVOTHYROXINE 0.025 MG TAB,2500012780,CDM,637,RC,6068745301,NDC,999,EAPG,,,,outpatient,facility,25,UN,1.84,1.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 0.05 MG TAB,2500012781,CDM,637,RC,904695061,NDC,,,,,,inpatient,facility,50,UN,1.55,1.55,0.12,1.55,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,
LEVOTHYROXINE 0.05 MG TAB,2500012781,CDM,637,RC,904695061,NDC,,,,,,outpatient,facility,50,UN,1.55,1.55,0.12,548.68,,1.1,,,percent of total billed charges,,,0.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.55,,,percent of total billed charges,,,0.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.55,,,fee schedule,,,1.55,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,0.91,,,percent of total billed charges,,,548.68,,,per diem,,,1.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.55,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,0.57,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,1.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.91,,,percent of total billed charges,,
LEVOTHYROXINE 0.05 MG TAB,2500012781,CDM,637,RC,904695061,NDC,999,EAPG,,,,outpatient,facility,50,UN,1.55,1.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 0.075 MG TAB,2500012782,CDM,637,RC,904695161,NDC,,,,,,inpatient,facility,75,UN,1.88,1.88,0.15,1.88,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,
LEVOTHYROXINE 0.075 MG TAB,2500012782,CDM,637,RC,904695161,NDC,,,,,,outpatient,facility,75,UN,1.88,1.88,0.15,548.68,,1.33,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.88,,,percent of total billed charges,,,1.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.69,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.88,,,fee schedule,,,1.88,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,1.11,,,percent of total billed charges,,,548.68,,,per diem,,,1.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.88,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,0.7,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.11,,,percent of total billed charges,,
LEVOTHYROXINE 0.075 MG TAB,2500012782,CDM,637,RC,904695161,NDC,999,EAPG,,,,outpatient,facility,75,UN,1.88,1.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 0.088 MG TAB,2500012783,CDM,637,RC,6818096803,NDC,,,,,,inpatient,facility,88,UN,1.85,1.85,0.15,1.85,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,
LEVOTHYROXINE 0.088 MG TAB,2500012783,CDM,637,RC,6818096803,NDC,,,,,,outpatient,facility,88,UN,1.85,1.85,0.15,548.68,,1.31,,,percent of total billed charges,,,0.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.85,,,percent of total billed charges,,,1.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.68,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.85,,,fee schedule,,,1.85,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,548.68,,,per diem,,,1.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.85,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.09,,,percent of total billed charges,,
LEVOTHYROXINE 0.088 MG TAB,2500012783,CDM,637,RC,6818096803,NDC,999,EAPG,,,,outpatient,facility,88,UN,1.85,1.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 0.1 MG TAB,2500012784,CDM,637,RC,904695361,NDC,,,,,,inpatient,facility,100,UN,1.94,1.94,0.16,1.94,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,
LEVOTHYROXINE 0.1 MG TAB,2500012784,CDM,637,RC,904695361,NDC,,,,,,outpatient,facility,100,UN,1.94,1.94,0.16,548.68,,1.38,,,percent of total billed charges,,,0.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.94,,,percent of total billed charges,,,1.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.94,,,fee schedule,,,1.94,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,1.14,,,percent of total billed charges,,,548.68,,,per diem,,,1.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.94,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,0.72,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.14,,,percent of total billed charges,,
LEVOTHYROXINE 0.1 MG TAB,2500012784,CDM,637,RC,904695361,NDC,999,EAPG,,,,outpatient,facility,100,UN,1.94,1.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 0.112 MG TAB,2500012785,CDM,637,RC,6818097003,NDC,,,,,,inpatient,facility,112,UN,2.15,2.15,0.17,2.15,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,2.15,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,
LEVOTHYROXINE 0.112 MG TAB,2500012785,CDM,637,RC,6818097003,NDC,,,,,,outpatient,facility,112,UN,2.15,2.15,0.17,548.68,,1.52,,,percent of total billed charges,,,0.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.15,,,percent of total billed charges,,,1.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.79,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.15,,,fee schedule,,,2.15,,,percent of total billed charges,,,,,,,,,2.15,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,1.27,,,percent of total billed charges,,,548.68,,,per diem,,,2.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.15,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,0.8,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,2.15,,,percent of total billed charges,,,2.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.27,,,percent of total billed charges,,
LEVOTHYROXINE 0.112 MG TAB,2500012785,CDM,637,RC,6818097003,NDC,999,EAPG,,,,outpatient,facility,112,UN,2.15,2.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 0.125 MG TAB,2500012786,CDM,637,RC,6818097103,NDC,,,,,,inpatient,facility,125,UN,2.18,2.18,0.17,2.18,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,
LEVOTHYROXINE 0.125 MG TAB,2500012786,CDM,637,RC,6818097103,NDC,,,,,,outpatient,facility,125,UN,2.18,2.18,0.17,548.68,,1.55,,,percent of total billed charges,,,0.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.18,,,percent of total billed charges,,,1.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.8,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.18,,,fee schedule,,,2.18,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,548.68,,,per diem,,,2.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.18,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,0.81,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.28,,,percent of total billed charges,,
LEVOTHYROXINE 0.125 MG TAB,2500012786,CDM,637,RC,6818097103,NDC,999,EAPG,,,,outpatient,facility,125,UN,2.18,2.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 0.15 MG TAB,2500012787,CDM,637,RC,6818097303,NDC,,,,,,inpatient,facility,150,UN,2.24,2.24,0.18,2.24,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,
LEVOTHYROXINE 0.15 MG TAB,2500012787,CDM,637,RC,6818097303,NDC,,,,,,outpatient,facility,150,UN,2.24,2.24,0.18,548.68,,1.59,,,percent of total billed charges,,,0.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.24,,,percent of total billed charges,,,1.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.82,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.24,,,fee schedule,,,2.24,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,548.68,,,per diem,,,2.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.24,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.32,,,percent of total billed charges,,
LEVOTHYROXINE 0.15 MG TAB,2500012787,CDM,637,RC,6818097303,NDC,999,EAPG,,,,outpatient,facility,150,UN,2.24,2.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVOTHYROXINE 100 MCG INJ,2500012794,CDM,636,RC,J0650,HCPCS,4202320101,NDC,,,,inpatient,facility,100,UN,348.41,348.41,27.87,348.41,,,,,,,,,,,,,,348.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.41,,,percent of total billed charges,,,,,,,,,348.41,,,percent of total billed charges,,,177.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.05,,,percent of total billed charges,,,,,,,,,,,,,,,348.41,,,percent of total billed charges,,,296.15,,,percent of total billed charges,,,,,,,,,,,,,,,348.41,,,percent of total billed charges,,,185.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,348.41,,,percent of total billed charges,,,,,,,,,,,,,,,27.87,,,percent of total billed charges,,,348.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,348.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.28,,,percent of total billed charges,,
LEVOTHYROXINE 100 MCG INJ,2500012794,CDM,636,RC,J0650,HCPCS,4202320101,NDC,,,,outpatient,facility,100,UN,348.41,348.41,14.79,548.68,,247.06,,,percent of total billed charges,,,85.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,348.41,,,percent of total billed charges,,,15.63,,,fee schedule,,,14.79,,,fee schedule,,,,,,,,,14.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,348.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,127.52,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,348.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,348.41,,,fee schedule,,,348.41,,,percent of total billed charges,,,,,,,,,348.41,,,percent of total billed charges,,,213.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.24,,,percent of total billed charges,,,,,,,,,,,,,,,188.14,,,percent of total billed charges,,,181.17,,,percent of total billed charges,,,191.63,,,percent of total billed charges,,,,,,,,,205.56,,,percent of total billed charges,,,548.68,,,per diem,,,348.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,348.41,,,percent of total billed charges,,,296.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,185.04,,,percent of total billed charges,,,348.41,,,percent of total billed charges,,,348.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.04,,,percent of total billed charges,,,281.93,,,percent of total billed charges,,,,,,,,,,,,,,,139.36,,,percent of total billed charges,,,,,,,,,128.91,,,percent of total billed charges,,,128.91,,,percent of total billed charges,,,,,,,,,348.41,,,percent of total billed charges,,,348.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,348.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.87,,,percent of total billed charges,,,348.41,,,percent of total billed charges,,,,,,,,,,,,,,,348.41,,,percent of total billed charges,,,348.41,,,percent of total billed charges,,,,,,,,,324.09,,,percent of total billed charges,,,,,,,,,,,,,,,324.09,,,percent of total billed charges,,,324.09,,,percent of total billed charges,,,324.09,,,percent of total billed charges,,,261.31,,,percent of total billed charges,,,348.41,,,percent of total billed charges,,,348.41,,,percent of total billed charges,,,348.41,,,percent of total billed charges,,,,,,,,,244.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,205.28,,,percent of total billed charges,,
LEVOTHYROXINE 100 MCG INJ,2500012794,CDM,636,RC,J0650,HCPCS,4202320101,NDC,436,EAPG,,outpatient,facility,100,UN,348.41,348.41,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 2  2 ML AMP,2500012815,CDM,636,RC,J2003,HCPCS,6332349527,NDC,,,,inpatient,facility,2,UN,9.67,9.67,0.77,9.67,,,,,,,,,,,,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.67,,,percent of total billed charges,,,,,,,,,9.67,,,percent of total billed charges,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,,,,,,,,,,,,,9.67,,,percent of total billed charges,,,8.22,,,percent of total billed charges,,,,,,,,,,,,,,,9.67,,,percent of total billed charges,,,5.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,
LIDOCAINE 2  2 ML AMP,2500012815,CDM,636,RC,J2003,HCPCS,6332349527,NDC,,,,outpatient,facility,2,UN,9.67,9.67,0.77,548.68,,6.86,,,percent of total billed charges,,,2.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.67,,,percent of total billed charges,,,6.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.54,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.67,,,fee schedule,,,9.67,,,percent of total billed charges,,,,,,,,,9.67,,,percent of total billed charges,,,5.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.89,,,percent of total billed charges,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,5.03,,,percent of total billed charges,,,5.32,,,percent of total billed charges,,,,,,,,,5.71,,,percent of total billed charges,,,548.68,,,per diem,,,9.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.67,,,percent of total billed charges,,,8.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.14,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.52,,,percent of total billed charges,,,7.82,,,percent of total billed charges,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,,,,,,,3.58,,,percent of total billed charges,,,3.58,,,percent of total billed charges,,,,,,,,,9.67,,,percent of total billed charges,,,9.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.77,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,9.67,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,,,,,,,9,,,percent of total billed charges,,,,,,,,,,,,,,,9,,,percent of total billed charges,,,9,,,percent of total billed charges,,,9,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,,,,,,,6.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.7,,,percent of total billed charges,,
LIDOCAINE 2  2 ML AMP,2500012815,CDM,636,RC,J2003,HCPCS,6332349527,NDC,999,EAPG,,outpatient,facility,2,UN,9.67,9.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 1 /10 ML INJ MPF,2500012823,CDM,250,RC,J2003,HCPCS,6332349297,NDC,,,,inpatient,facility,10,UN,8.05,8.05,0.64,8.05,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,8.05,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.83,,,percent of total billed charges,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,6.84,,,percent of total billed charges,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,4.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.74,,,percent of total billed charges,,
LIDOCAINE HCL 1 /10 ML INJ MPF,2500012823,CDM,250,RC,J2003,HCPCS,6332349297,NDC,,,,outpatient,facility,10,UN,8.05,8.05,0.64,548.68,,5.71,,,percent of total billed charges,,,1.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.05,,,percent of total billed charges,,,5.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.95,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.05,,,fee schedule,,,8.05,,,percent of total billed charges,,,,,,,,,8.05,,,percent of total billed charges,,,4.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,4.75,,,percent of total billed charges,,,548.68,,,per diem,,,8.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.05,,,percent of total billed charges,,,6.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.43,,,percent of total billed charges,,,6.51,,,percent of total billed charges,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,,,,,,,2.98,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,,,,,,,8.05,,,percent of total billed charges,,,8.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.64,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,6.04,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.74,,,percent of total billed charges,,
LIDOCAINE HCL 1 /10 ML INJ MPF,2500012823,CDM,250,RC,J2003,HCPCS,6332349297,NDC,999,EAPG,,outpatient,facility,10,UN,8.05,8.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 1   2 ML AMP,2500012824,CDM,250,RC,J2003,HCPCS,6332349227,NDC,,,,inpatient,facility,2,UN,7.79,7.79,0.62,7.79,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,,,,,,,7.79,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.67,,,percent of total billed charges,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,6.62,,,percent of total billed charges,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,4.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,
LIDOCAINE HCL 1   2 ML AMP,2500012824,CDM,250,RC,J2003,HCPCS,6332349227,NDC,,,,outpatient,facility,2,UN,7.79,7.79,0.62,548.68,,5.52,,,percent of total billed charges,,,1.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.79,,,percent of total billed charges,,,4.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.85,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.79,,,fee schedule,,,7.79,,,percent of total billed charges,,,,,,,,,7.79,,,percent of total billed charges,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,4.6,,,percent of total billed charges,,,548.68,,,per diem,,,7.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.79,,,percent of total billed charges,,,6.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.14,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.26,,,percent of total billed charges,,,6.3,,,percent of total billed charges,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,,,,,,,2.88,,,percent of total billed charges,,,2.88,,,percent of total billed charges,,,,,,,,,7.79,,,percent of total billed charges,,,7.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.62,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,5.84,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,5.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.59,,,percent of total billed charges,,
LIDOCAINE HCL 1   2 ML AMP,2500012824,CDM,250,RC,J2003,HCPCS,6332349227,NDC,999,EAPG,,outpatient,facility,2,UN,7.79,7.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 1   20ML INJ MDV,2500012825,CDM,250,RC,J2003,HCPCS,5515025220,NDC,,,,inpatient,facility,20,ML,14.65,14.65,1.17,14.65,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,,,,,,,14.65,,,percent of total billed charges,,,7.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.79,,,percent of total billed charges,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,12.45,,,percent of total billed charges,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,7.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.63,,,percent of total billed charges,,
LIDOCAINE HCL 1   20ML INJ MDV,2500012825,CDM,250,RC,J2003,HCPCS,5515025220,NDC,,,,outpatient,facility,20,ML,14.65,14.65,1.17,548.68,,10.39,,,percent of total billed charges,,,3.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.65,,,percent of total billed charges,,,9.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.65,,,fee schedule,,,14.65,,,percent of total billed charges,,,,,,,,,14.65,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,8.64,,,percent of total billed charges,,,548.68,,,per diem,,,14.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.65,,,percent of total billed charges,,,12.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.78,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.88,,,percent of total billed charges,,,11.85,,,percent of total billed charges,,,,,,,,,,,,,,,5.86,,,percent of total billed charges,,,,,,,,,5.42,,,percent of total billed charges,,,5.42,,,percent of total billed charges,,,,,,,,,14.65,,,percent of total billed charges,,,14.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.17,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,,,,,,,13.63,,,percent of total billed charges,,,,,,,,,,,,,,,13.63,,,percent of total billed charges,,,13.63,,,percent of total billed charges,,,13.63,,,percent of total billed charges,,,10.99,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,,,,,,,10.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.33,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.63,,,percent of total billed charges,,
LIDOCAINE HCL 1   20ML INJ MDV,2500012825,CDM,250,RC,J2003,HCPCS,5515025220,NDC,999,EAPG,,outpatient,facility,20,ML,14.65,14.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 100 MG/5 ML SYR,2500012832,CDM,636,RC,J2003,HCPCS,409490334,NDC,,,,inpatient,facility,5,ML,20.69,20.69,1.66,20.69,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,,,,,,,20.69,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.41,,,percent of total billed charges,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,17.59,,,percent of total billed charges,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,10.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.19,,,percent of total billed charges,,
LIDOCAINE HCL 100 MG/5 ML SYR,2500012832,CDM,636,RC,J2003,HCPCS,409490334,NDC,,,,outpatient,facility,5,ML,20.69,20.69,1.66,548.68,,14.67,,,percent of total billed charges,,,5.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,20.69,,,percent of total billed charges,,,12.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,14.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,14.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,20.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,20.69,,,fee schedule,,,20.69,,,percent of total billed charges,,,,,,,,,20.69,,,percent of total billed charges,,,12.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.74,,,percent of total billed charges,,,,,,,,,,,,,,,11.17,,,percent of total billed charges,,,10.76,,,percent of total billed charges,,,11.38,,,percent of total billed charges,,,,,,,,,12.21,,,percent of total billed charges,,,548.68,,,per diem,,,20.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,20.69,,,percent of total billed charges,,,17.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.99,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.96,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,,,,,,,,,,,,,8.28,,,percent of total billed charges,,,,,,,,,7.66,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,20.69,,,percent of total billed charges,,,20.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.66,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,,,,,,,19.25,,,percent of total billed charges,,,,,,,,,,,,,,,19.25,,,percent of total billed charges,,,19.25,,,percent of total billed charges,,,19.25,,,percent of total billed charges,,,15.52,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,,,,,,,14.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,12.19,,,percent of total billed charges,,
LIDOCAINE HCL 100 MG/5 ML SYR,2500012832,CDM,636,RC,J2003,HCPCS,409490334,NDC,999,EAPG,,outpatient,facility,5,ML,20.69,20.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 2  GEL 10 ML SYR,2500012837,CDM,250,RC,7632930135,NDC,,,,,,inpatient,facility,10,UN,23.23,23.23,1.86,23.23,,,,,,,,,,,,,,23.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.23,,,percent of total billed charges,,,,,,,,,23.23,,,percent of total billed charges,,,11.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.94,,,percent of total billed charges,,,,,,,,,,,,,,,23.23,,,percent of total billed charges,,,19.75,,,percent of total billed charges,,,,,,,,,,,,,,,23.23,,,percent of total billed charges,,,12.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,23.23,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,23.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,
LIDOCAINE HCL 2  GEL 10 ML SYR,2500012837,CDM,250,RC,7632930135,NDC,,,,,,outpatient,facility,10,UN,23.23,23.23,1.86,548.68,,16.47,,,percent of total billed charges,,,5.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,23.23,,,percent of total billed charges,,,14.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,16.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,16.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,23.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.5,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,23.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,23.23,,,fee schedule,,,23.23,,,percent of total billed charges,,,,,,,,,23.23,,,percent of total billed charges,,,14.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,13.71,,,percent of total billed charges,,,548.68,,,per diem,,,23.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,23.23,,,percent of total billed charges,,,19.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.34,,,percent of total billed charges,,,23.23,,,percent of total billed charges,,,23.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.67,,,percent of total billed charges,,,18.8,,,percent of total billed charges,,,,,,,,,,,,,,,9.29,,,percent of total billed charges,,,,,,,,,9.29,,,percent of total billed charges,,,9.29,,,percent of total billed charges,,,,,,,,,23.23,,,percent of total billed charges,,,23.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.86,,,percent of total billed charges,,,23.23,,,percent of total billed charges,,,,,,,,,,,,,,,23.23,,,percent of total billed charges,,,23.23,,,percent of total billed charges,,,,,,,,,9.29,,,percent of total billed charges,,,,,,,,,,,,,,,9.29,,,percent of total billed charges,,,9.29,,,percent of total billed charges,,,9.29,,,percent of total billed charges,,,17.42,,,percent of total billed charges,,,23.23,,,percent of total billed charges,,,23.23,,,percent of total billed charges,,,23.23,,,percent of total billed charges,,,,,,,,,16.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.62,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.69,,,percent of total billed charges,,
LIDOCAINE HCL 2  GEL 10 ML SYR,2500012837,CDM,250,RC,7632930135,NDC,999,EAPG,,,,outpatient,facility,10,UN,23.23,23.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 2  JELLY 30 ML,2500012838,CDM,637,RC,1747871130,NDC,,,,,,inpatient,facility,30,UN,423.56,423.56,33.88,423.56,,,,,,,,,,,,,,423.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,423.56,,,percent of total billed charges,,,,,,,,,423.56,,,percent of total billed charges,,,216.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.14,,,percent of total billed charges,,,,,,,,,,,,,,,423.56,,,percent of total billed charges,,,360.03,,,percent of total billed charges,,,,,,,,,,,,,,,423.56,,,percent of total billed charges,,,224.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,423.56,,,percent of total billed charges,,,,,,,,,,,,,,,33.88,,,percent of total billed charges,,,423.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,423.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.56,,,percent of total billed charges,,
LIDOCAINE HCL 2  JELLY 30 ML,2500012838,CDM,637,RC,1747871130,NDC,,,,,,outpatient,facility,30,UN,423.56,423.56,33.88,548.68,,300.35,,,percent of total billed charges,,,103.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,423.56,,,percent of total billed charges,,,265.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,297.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,297.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,423.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,155.02,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,423.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,423.56,,,fee schedule,,,423.56,,,percent of total billed charges,,,,,,,,,423.56,,,percent of total billed charges,,,259.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.79,,,percent of total billed charges,,,,,,,,,,,,,,,228.72,,,percent of total billed charges,,,220.25,,,percent of total billed charges,,,232.96,,,percent of total billed charges,,,,,,,,,249.9,,,percent of total billed charges,,,548.68,,,per diem,,,423.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,423.56,,,percent of total billed charges,,,360.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,224.95,,,percent of total billed charges,,,423.56,,,percent of total billed charges,,,423.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,285.73,,,percent of total billed charges,,,342.74,,,percent of total billed charges,,,,,,,,,,,,,,,169.42,,,percent of total billed charges,,,,,,,,,156.72,,,percent of total billed charges,,,156.72,,,percent of total billed charges,,,,,,,,,423.56,,,percent of total billed charges,,,423.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,423.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33.88,,,percent of total billed charges,,,423.56,,,percent of total billed charges,,,,,,,,,,,,,,,423.56,,,percent of total billed charges,,,423.56,,,percent of total billed charges,,,,,,,,,394,,,percent of total billed charges,,,,,,,,,,,,,,,394,,,percent of total billed charges,,,394,,,percent of total billed charges,,,394,,,percent of total billed charges,,,317.67,,,percent of total billed charges,,,423.56,,,percent of total billed charges,,,423.56,,,percent of total billed charges,,,423.56,,,percent of total billed charges,,,,,,,,,296.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,249.56,,,percent of total billed charges,,
LIDOCAINE HCL 2  JELLY 30 ML,2500012838,CDM,637,RC,1747871130,NDC,999,EAPG,,,,outpatient,facility,30,UN,423.56,423.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 2  URO-JET 20 ML,2500012840,CDM,637,RC,7632930155,NDC,,,,,,inpatient,facility,20,UN,33.56,33.56,2.68,33.56,,,,,,,,,,,,,,33.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.56,,,percent of total billed charges,,,,,,,,,33.56,,,percent of total billed charges,,,17.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.14,,,percent of total billed charges,,,,,,,,,,,,,,,33.56,,,percent of total billed charges,,,28.53,,,percent of total billed charges,,,,,,,,,,,,,,,33.56,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,33.56,,,percent of total billed charges,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,33.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.77,,,percent of total billed charges,,
LIDOCAINE HCL 2  URO-JET 20 ML,2500012840,CDM,637,RC,7632930155,NDC,,,,,,outpatient,facility,20,UN,33.56,33.56,2.68,548.68,,23.8,,,percent of total billed charges,,,8.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,33.56,,,percent of total billed charges,,,21.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,23.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,23.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,33.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.28,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,33.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,33.56,,,fee schedule,,,33.56,,,percent of total billed charges,,,,,,,,,33.56,,,percent of total billed charges,,,20.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.91,,,percent of total billed charges,,,,,,,,,,,,,,,18.12,,,percent of total billed charges,,,17.45,,,percent of total billed charges,,,18.46,,,percent of total billed charges,,,,,,,,,19.8,,,percent of total billed charges,,,548.68,,,per diem,,,33.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,33.56,,,percent of total billed charges,,,28.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,33.56,,,percent of total billed charges,,,33.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.64,,,percent of total billed charges,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,13.42,,,percent of total billed charges,,,,,,,,,12.42,,,percent of total billed charges,,,12.42,,,percent of total billed charges,,,,,,,,,33.56,,,percent of total billed charges,,,33.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.68,,,percent of total billed charges,,,33.56,,,percent of total billed charges,,,,,,,,,,,,,,,33.56,,,percent of total billed charges,,,33.56,,,percent of total billed charges,,,,,,,,,31.22,,,percent of total billed charges,,,,,,,,,,,,,,,31.22,,,percent of total billed charges,,,31.22,,,percent of total billed charges,,,31.22,,,percent of total billed charges,,,25.17,,,percent of total billed charges,,,33.56,,,percent of total billed charges,,,33.56,,,percent of total billed charges,,,33.56,,,percent of total billed charges,,,,,,,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,19.77,,,percent of total billed charges,,
LIDOCAINE HCL 2  URO-JET 20 ML,2500012840,CDM,637,RC,7632930155,NDC,999,EAPG,,,,outpatient,facility,20,UN,33.56,33.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 2  VISC 100 ML,2500012842,CDM,637,RC,527600274,NDC,,,,,,inpatient,facility,100,UN,43.56,43.56,3.48,43.56,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,,,,,,,43.56,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.14,,,percent of total billed charges,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,37.03,,,percent of total billed charges,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,3.48,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.67,,,percent of total billed charges,,
LIDOCAINE HCL 2  VISC 100 ML,2500012842,CDM,637,RC,527600274,NDC,,,,,,outpatient,facility,100,UN,43.56,43.56,3.48,548.68,,30.89,,,percent of total billed charges,,,10.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,43.56,,,percent of total billed charges,,,27.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,30.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,30.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,15.94,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,43.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,43.56,,,fee schedule,,,43.56,,,percent of total billed charges,,,,,,,,,43.56,,,percent of total billed charges,,,26.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.04,,,percent of total billed charges,,,,,,,,,,,,,,,23.52,,,percent of total billed charges,,,22.65,,,percent of total billed charges,,,23.96,,,percent of total billed charges,,,,,,,,,25.7,,,percent of total billed charges,,,548.68,,,per diem,,,43.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,43.56,,,percent of total billed charges,,,37.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.39,,,percent of total billed charges,,,35.25,,,percent of total billed charges,,,,,,,,,,,,,,,17.42,,,percent of total billed charges,,,,,,,,,16.12,,,percent of total billed charges,,,16.12,,,percent of total billed charges,,,,,,,,,43.56,,,percent of total billed charges,,,43.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.48,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,,,,,,,40.52,,,percent of total billed charges,,,,,,,,,,,,,,,40.52,,,percent of total billed charges,,,40.52,,,percent of total billed charges,,,40.52,,,percent of total billed charges,,,32.67,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,43.56,,,percent of total billed charges,,,,,,,,,30.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,25.67,,,percent of total billed charges,,
LIDOCAINE HCL 2  VISC 100 ML,2500012842,CDM,637,RC,527600274,NDC,999,EAPG,,,,outpatient,facility,100,UN,43.56,43.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 2  VISC 20ML UDC,2500012843,CDM,637,RC,527600274,NDC,,,,,,inpatient,facility,20,UN,8.71,8.71,0.7,8.71,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,,,,,,,8.71,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.23,,,percent of total billed charges,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,4.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.13,,,percent of total billed charges,,
LIDOCAINE HCL 2  VISC 20ML UDC,2500012843,CDM,637,RC,527600274,NDC,,,,,,outpatient,facility,20,UN,8.71,8.71,0.7,548.68,,6.18,,,percent of total billed charges,,,2.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.71,,,percent of total billed charges,,,5.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.19,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.71,,,fee schedule,,,8.71,,,percent of total billed charges,,,,,,,,,8.71,,,percent of total billed charges,,,5.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.21,,,percent of total billed charges,,,,,,,,,,,,,,,4.7,,,percent of total billed charges,,,4.53,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,,,,,,,5.14,,,percent of total billed charges,,,548.68,,,per diem,,,8.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.71,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.88,,,percent of total billed charges,,,7.05,,,percent of total billed charges,,,,,,,,,,,,,,,3.48,,,percent of total billed charges,,,,,,,,,3.22,,,percent of total billed charges,,,3.22,,,percent of total billed charges,,,,,,,,,8.71,,,percent of total billed charges,,,8.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.7,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,,,,,,,8.1,,,percent of total billed charges,,,,,,,,,,,,,,,8.1,,,percent of total billed charges,,,8.1,,,percent of total billed charges,,,8.1,,,percent of total billed charges,,,6.53,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,,,,,,,6.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.13,,,percent of total billed charges,,
LIDOCAINE HCL 2  VISC 20ML UDC,2500012843,CDM,637,RC,527600274,NDC,999,EAPG,,,,outpatient,facility,20,UN,8.71,8.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 4  TOP 50 ML INJ,2500012849,CDM,637,RC,5256500950,NDC,,,,,,inpatient,facility,50,UN,158.4,158.4,12.67,158.4,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,158.4,,,percent of total billed charges,,,80.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.04,,,percent of total billed charges,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,134.64,,,percent of total billed charges,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,84.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,12.67,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.33,,,percent of total billed charges,,
LIDOCAINE HCL 4  TOP 50 ML INJ,2500012849,CDM,637,RC,5256500950,NDC,,,,,,outpatient,facility,50,UN,158.4,158.4,12.67,548.68,,112.32,,,percent of total billed charges,,,38.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,158.4,,,percent of total billed charges,,,99.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,111.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,111.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,57.97,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,158.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,158.4,,,fee schedule,,,158.4,,,percent of total billed charges,,,,,,,,,158.4,,,percent of total billed charges,,,97.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.86,,,percent of total billed charges,,,,,,,,,,,,,,,85.54,,,percent of total billed charges,,,82.37,,,percent of total billed charges,,,87.12,,,percent of total billed charges,,,,,,,,,93.46,,,percent of total billed charges,,,548.68,,,per diem,,,158.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,158.4,,,percent of total billed charges,,,134.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,84.13,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.86,,,percent of total billed charges,,,128.18,,,percent of total billed charges,,,,,,,,,,,,,,,63.36,,,percent of total billed charges,,,,,,,,,58.61,,,percent of total billed charges,,,58.61,,,percent of total billed charges,,,,,,,,,158.4,,,percent of total billed charges,,,158.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,158.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.67,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,,,,,,,147.34,,,percent of total billed charges,,,,,,,,,,,,,,,147.34,,,percent of total billed charges,,,147.34,,,percent of total billed charges,,,147.34,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,,,,,,,111.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,93.33,,,percent of total billed charges,,
LIDOCAINE HCL 4  TOP 50 ML INJ,2500012849,CDM,637,RC,5256500950,NDC,999,EAPG,,,,outpatient,facility,50,UN,158.4,158.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 5  OINT 35 GM,2500012850,CDM,637,RC,6846241820,NDC,,,,,,inpatient,facility,35,UN,34.65,34.65,2.77,34.65,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,34.65,,,percent of total billed charges,,,17.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,29.45,,,percent of total billed charges,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,18.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.42,,,percent of total billed charges,,
LIDOCAINE HCL 5  OINT 35 GM,2500012850,CDM,637,RC,6846241820,NDC,,,,,,outpatient,facility,35,UN,34.65,34.65,2.77,548.68,,24.57,,,percent of total billed charges,,,8.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,34.65,,,percent of total billed charges,,,21.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,24.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,24.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.68,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,34.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,34.65,,,fee schedule,,,34.65,,,percent of total billed charges,,,,,,,,,34.65,,,percent of total billed charges,,,21.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.69,,,percent of total billed charges,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,18.02,,,percent of total billed charges,,,19.06,,,percent of total billed charges,,,,,,,,,20.44,,,percent of total billed charges,,,548.68,,,per diem,,,34.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,34.65,,,percent of total billed charges,,,29.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.4,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.37,,,percent of total billed charges,,,28.04,,,percent of total billed charges,,,,,,,,,,,,,,,13.86,,,percent of total billed charges,,,,,,,,,12.82,,,percent of total billed charges,,,12.82,,,percent of total billed charges,,,,,,,,,34.65,,,percent of total billed charges,,,34.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,34.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.77,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,32.23,,,percent of total billed charges,,,,,,,,,,,,,,,32.23,,,percent of total billed charges,,,32.23,,,percent of total billed charges,,,32.23,,,percent of total billed charges,,,25.99,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,24.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,20.42,,,percent of total billed charges,,
LIDOCAINE HCL 5  OINT 35 GM,2500012850,CDM,637,RC,6846241820,NDC,999,EAPG,,,,outpatient,facility,35,UN,34.65,34.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 5  PATCH,2500012852,CDM,637,RC,591352530,NDC,,,,,,inpatient,facility,1,UN,30.89,30.89,2.47,30.89,,,,,,,,,,,,,,30.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.89,,,percent of total billed charges,,,,,,,,,30.89,,,percent of total billed charges,,,15.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.53,,,percent of total billed charges,,,,,,,,,,,,,,,30.89,,,percent of total billed charges,,,26.26,,,percent of total billed charges,,,,,,,,,,,,,,,30.89,,,percent of total billed charges,,,16.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,30.89,,,percent of total billed charges,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,30.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.2,,,percent of total billed charges,,
LIDOCAINE HCL 5  PATCH,2500012852,CDM,637,RC,591352530,NDC,,,,,,outpatient,facility,1,UN,30.89,30.89,2.47,548.68,,21.9,,,percent of total billed charges,,,7.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,30.89,,,percent of total billed charges,,,19.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,21.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,21.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,30.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.31,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,30.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,30.89,,,fee schedule,,,30.89,,,percent of total billed charges,,,,,,,,,30.89,,,percent of total billed charges,,,18.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.01,,,percent of total billed charges,,,,,,,,,,,,,,,16.68,,,percent of total billed charges,,,16.06,,,percent of total billed charges,,,16.99,,,percent of total billed charges,,,,,,,,,18.23,,,percent of total billed charges,,,548.68,,,per diem,,,30.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,30.89,,,percent of total billed charges,,,26.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.41,,,percent of total billed charges,,,30.89,,,percent of total billed charges,,,30.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.84,,,percent of total billed charges,,,25,,,percent of total billed charges,,,,,,,,,,,,,,,12.36,,,percent of total billed charges,,,,,,,,,11.43,,,percent of total billed charges,,,11.43,,,percent of total billed charges,,,,,,,,,30.89,,,percent of total billed charges,,,30.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.47,,,percent of total billed charges,,,30.89,,,percent of total billed charges,,,,,,,,,,,,,,,30.89,,,percent of total billed charges,,,30.89,,,percent of total billed charges,,,,,,,,,28.73,,,percent of total billed charges,,,,,,,,,,,,,,,28.73,,,percent of total billed charges,,,28.73,,,percent of total billed charges,,,28.73,,,percent of total billed charges,,,23.17,,,percent of total billed charges,,,30.89,,,percent of total billed charges,,,30.89,,,percent of total billed charges,,,30.89,,,percent of total billed charges,,,,,,,,,21.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.2,,,percent of total billed charges,,
LIDOCAINE HCL 5  PATCH,2500012852,CDM,637,RC,591352530,NDC,999,EAPG,,,,outpatient,facility,1,UN,30.89,30.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 2  VISC 15ML UDC,2500012855,CDM,637,RC,5038336317,NDC,,,,,,inpatient,facility,15,UN,3.56,3.56,0.28,3.56,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,3.56,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.1,,,percent of total billed charges,,
LIDOCAINE HCL 2  VISC 15ML UDC,2500012855,CDM,637,RC,5038336317,NDC,,,,,,outpatient,facility,15,UN,3.56,3.56,0.28,548.68,,2.52,,,percent of total billed charges,,,0.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.56,,,percent of total billed charges,,,2.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.56,,,fee schedule,,,3.56,,,percent of total billed charges,,,,,,,,,3.56,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,2.1,,,percent of total billed charges,,,548.68,,,per diem,,,3.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.56,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,2.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,3.56,,,percent of total billed charges,,,3.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.1,,,percent of total billed charges,,
LIDOCAINE HCL 2  VISC 15ML UDC,2500012855,CDM,637,RC,5038336317,NDC,999,EAPG,,,,outpatient,facility,15,UN,3.56,3.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE/PRILOCAINE 5 GM KIT,2500012868,CDM,637,RC,168035756,NDC,,,,,,inpatient,facility,5,UN,136.36,136.36,10.91,136.36,,,,,,,,,,,,,,136.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.36,,,percent of total billed charges,,,,,,,,,136.36,,,percent of total billed charges,,,69.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.82,,,percent of total billed charges,,,,,,,,,,,,,,,136.36,,,percent of total billed charges,,,115.91,,,percent of total billed charges,,,,,,,,,,,,,,,136.36,,,percent of total billed charges,,,72.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,136.36,,,percent of total billed charges,,,,,,,,,,,,,,,10.91,,,percent of total billed charges,,,136.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,136.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.34,,,percent of total billed charges,,
LIDOCAINE/PRILOCAINE 5 GM KIT,2500012868,CDM,637,RC,168035756,NDC,,,,,,outpatient,facility,5,UN,136.36,136.36,10.91,548.68,,96.69,,,percent of total billed charges,,,33.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,136.36,,,percent of total billed charges,,,85.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,95.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,95.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,136.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,49.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,136.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,136.36,,,fee schedule,,,136.36,,,percent of total billed charges,,,,,,,,,136.36,,,percent of total billed charges,,,83.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.16,,,percent of total billed charges,,,,,,,,,,,,,,,73.63,,,percent of total billed charges,,,70.91,,,percent of total billed charges,,,75,,,percent of total billed charges,,,,,,,,,80.45,,,percent of total billed charges,,,548.68,,,per diem,,,136.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,136.36,,,percent of total billed charges,,,115.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.42,,,percent of total billed charges,,,136.36,,,percent of total billed charges,,,136.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.99,,,percent of total billed charges,,,110.34,,,percent of total billed charges,,,,,,,,,,,,,,,54.54,,,percent of total billed charges,,,,,,,,,50.45,,,percent of total billed charges,,,50.45,,,percent of total billed charges,,,,,,,,,136.36,,,percent of total billed charges,,,136.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,136.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.91,,,percent of total billed charges,,,136.36,,,percent of total billed charges,,,,,,,,,,,,,,,136.36,,,percent of total billed charges,,,136.36,,,percent of total billed charges,,,,,,,,,126.84,,,percent of total billed charges,,,,,,,,,,,,,,,126.84,,,percent of total billed charges,,,126.84,,,percent of total billed charges,,,126.84,,,percent of total billed charges,,,102.27,,,percent of total billed charges,,,136.36,,,percent of total billed charges,,,136.36,,,percent of total billed charges,,,136.36,,,percent of total billed charges,,,,,,,,,95.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,80.34,,,percent of total billed charges,,
LIDOCAINE/PRILOCAINE 5 GM KIT,2500012868,CDM,637,RC,168035756,NDC,999,EAPG,,,,outpatient,facility,5,UN,136.36,136.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEZOLID 600 MG TAB,2500012880,CDM,637,RC,904655304,NDC,,,,,,inpatient,facility,600,UN,20.43,20.43,1.63,20.43,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,,,,,,,20.43,,,percent of total billed charges,,,10.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.26,,,percent of total billed charges,,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,17.37,,,percent of total billed charges,,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,10.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.04,,,percent of total billed charges,,
LINEZOLID 600 MG TAB,2500012880,CDM,637,RC,904655304,NDC,,,,,,outpatient,facility,600,UN,20.43,20.43,1.63,548.68,,14.49,,,percent of total billed charges,,,4.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,20.43,,,percent of total billed charges,,,12.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,14.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,14.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.48,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,20.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,20.43,,,fee schedule,,,20.43,,,percent of total billed charges,,,,,,,,,20.43,,,percent of total billed charges,,,12.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.56,,,percent of total billed charges,,,,,,,,,,,,,,,11.03,,,percent of total billed charges,,,10.62,,,percent of total billed charges,,,11.24,,,percent of total billed charges,,,,,,,,,12.05,,,percent of total billed charges,,,548.68,,,per diem,,,20.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,20.43,,,percent of total billed charges,,,17.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.85,,,percent of total billed charges,,,20.43,,,percent of total billed charges,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.78,,,percent of total billed charges,,,16.53,,,percent of total billed charges,,,,,,,,,,,,,,,8.17,,,percent of total billed charges,,,,,,,,,7.56,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,,,,,,,20.43,,,percent of total billed charges,,,20.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.63,,,percent of total billed charges,,,20.43,,,percent of total billed charges,,,,,,,,,,,,,,,20.43,,,percent of total billed charges,,,20.43,,,percent of total billed charges,,,,,,,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,19,,,percent of total billed charges,,,19,,,percent of total billed charges,,,19,,,percent of total billed charges,,,15.32,,,percent of total billed charges,,,20.43,,,percent of total billed charges,,,20.43,,,percent of total billed charges,,,20.43,,,percent of total billed charges,,,,,,,,,14.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,12.04,,,percent of total billed charges,,
LINEZOLID 600 MG TAB,2500012880,CDM,637,RC,904655304,NDC,999,EAPG,,,,outpatient,facility,600,UN,20.43,20.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINEZOLID 600MG PREMIX IN 300,2500012885,CDM,636,RC,J2020,HCPCS,5766468357,NDC,,,,inpatient,facility,300,UN,82.5,82.5,6.6,82.5,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,82.5,,,percent of total billed charges,,,42.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,70.12,,,percent of total billed charges,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,43.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.61,,,percent of total billed charges,,
LINEZOLID 600MG PREMIX IN 300,2500012885,CDM,636,RC,J2020,HCPCS,5766468357,NDC,,,,outpatient,facility,300,UN,82.5,82.5,2.72,548.68,,58.5,,,percent of total billed charges,,,20.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,82.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,30.2,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,82.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,82.5,,,fee schedule,,,82.5,,,percent of total billed charges,,,,,,,,,82.5,,,percent of total billed charges,,,50.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.78,,,percent of total billed charges,,,,,,,,,,,,,,,3.3,,,fee schedule,,,3.3,,,fee schedule,,,3.3,,,fee schedule,,,,,,,,,48.68,,,percent of total billed charges,,,548.68,,,per diem,,,82.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,82.5,,,percent of total billed charges,,,70.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.82,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.65,,,percent of total billed charges,,,66.76,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,82.5,,,percent of total billed charges,,,82.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,82.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.6,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.72,,,fee schedule,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,57.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,48.61,,,percent of total billed charges,,
LINEZOLID 600MG PREMIX IN 300,2500012885,CDM,636,RC,J2020,HCPCS,5766468357,NDC,435,EAPG,,outpatient,facility,300,UN,82.5,82.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIPASE/AMYLASE/PROTEASE CAP,2500012914,CDM,637,RC,32263601,NDC,,,,,,inpatient,facility,24000,UN,27.16,27.16,2.17,27.16,,,,,,,,,,,,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.16,,,percent of total billed charges,,,,,,,,,27.16,,,percent of total billed charges,,,13.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.3,,,percent of total billed charges,,,,,,,,,,,,,,,27.16,,,percent of total billed charges,,,23.09,,,percent of total billed charges,,,,,,,,,,,,,,,27.16,,,percent of total billed charges,,,14.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16,,,percent of total billed charges,,
LIPASE/AMYLASE/PROTEASE CAP,2500012914,CDM,637,RC,32263601,NDC,,,,,,outpatient,facility,24000,UN,27.16,27.16,2.17,548.68,,19.26,,,percent of total billed charges,,,6.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,27.16,,,percent of total billed charges,,,17.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,19.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,19.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.94,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,27.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,27.16,,,fee schedule,,,27.16,,,percent of total billed charges,,,,,,,,,27.16,,,percent of total billed charges,,,16.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.35,,,percent of total billed charges,,,,,,,,,,,,,,,14.67,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,14.94,,,percent of total billed charges,,,,,,,,,16.02,,,percent of total billed charges,,,548.68,,,per diem,,,27.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,27.16,,,percent of total billed charges,,,23.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.42,,,percent of total billed charges,,,27.16,,,percent of total billed charges,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.32,,,percent of total billed charges,,,21.98,,,percent of total billed charges,,,,,,,,,,,,,,,10.86,,,percent of total billed charges,,,,,,,,,10.05,,,percent of total billed charges,,,10.05,,,percent of total billed charges,,,,,,,,,27.16,,,percent of total billed charges,,,27.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.17,,,percent of total billed charges,,,27.16,,,percent of total billed charges,,,,,,,,,,,,,,,27.16,,,percent of total billed charges,,,27.16,,,percent of total billed charges,,,,,,,,,25.26,,,percent of total billed charges,,,,,,,,,,,,,,,25.26,,,percent of total billed charges,,,25.26,,,percent of total billed charges,,,25.26,,,percent of total billed charges,,,20.37,,,percent of total billed charges,,,27.16,,,percent of total billed charges,,,27.16,,,percent of total billed charges,,,27.16,,,percent of total billed charges,,,,,,,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,16,,,percent of total billed charges,,
LIPASE/AMYLASE/PROTEASE CAP,2500012914,CDM,637,RC,32263601,NDC,999,EAPG,,,,outpatient,facility,24000,UN,27.16,27.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LISINOPRIL 10 MG TAB,2500012930,CDM,637,RC,6818098003,NDC,,,,,,inpatient,facility,10,UN,3.23,3.23,0.26,3.23,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,
LISINOPRIL 10 MG TAB,2500012930,CDM,637,RC,6818098003,NDC,,,,,,outpatient,facility,10,UN,3.23,3.23,0.26,548.68,,2.29,,,percent of total billed charges,,,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.23,,,percent of total billed charges,,,2.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.23,,,fee schedule,,,3.23,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,1.91,,,percent of total billed charges,,,548.68,,,per diem,,,3.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.23,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,1.2,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,3.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.9,,,percent of total billed charges,,
LISINOPRIL 10 MG TAB,2500012930,CDM,637,RC,6818098003,NDC,999,EAPG,,,,outpatient,facility,10,UN,3.23,3.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LISINOPRIL 20 MG TAB,2500012932,CDM,637,RC,904679961,NDC,,,,,,inpatient,facility,20,UN,0.23,0.23,0.02,0.23,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,
LISINOPRIL 20 MG TAB,2500012932,CDM,637,RC,904679961,NDC,,,,,,outpatient,facility,20,UN,0.23,0.23,0.02,548.68,,0.16,,,percent of total billed charges,,,0.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,0.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.23,,,fee schedule,,,0.23,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,0.14,,,percent of total billed charges,,,548.68,,,per diem,,,0.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.23,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,,,,,,,0.09,,,percent of total billed charges,,,0.09,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,0.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.14,,,percent of total billed charges,,
LISINOPRIL 20 MG TAB,2500012932,CDM,637,RC,904679961,NDC,999,EAPG,,,,outpatient,facility,20,UN,0.23,0.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LISINOPRIL 5 MG TAB,2500012934,CDM,637,RC,904679761,NDC,,,,,,inpatient,facility,5,UN,0.2,0.2,0.02,0.2,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,0.2,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,
LISINOPRIL 5 MG TAB,2500012934,CDM,637,RC,904679761,NDC,,,,,,outpatient,facility,5,UN,0.2,0.2,0.02,548.68,,0.14,,,percent of total billed charges,,,0.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,0.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.07,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.2,,,fee schedule,,,0.2,,,percent of total billed charges,,,,,,,,,0.2,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,0.12,,,percent of total billed charges,,,548.68,,,per diem,,,0.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.2,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,,,,,,,0.07,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,,,,,,,0.2,,,percent of total billed charges,,,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,0.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.12,,,percent of total billed charges,,
LISINOPRIL 5 MG TAB,2500012934,CDM,637,RC,904679761,NDC,999,EAPG,,,,outpatient,facility,5,UN,0.2,0.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LISINOPRIL 30 MG TAB,2500012935,CDM,637,RC,6818098201,NDC,,,,,,inpatient,facility,30,UN,4.98,4.98,0.4,4.98,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,,,,,,,4.98,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,4.23,,,percent of total billed charges,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,
LISINOPRIL 30 MG TAB,2500012935,CDM,637,RC,6818098201,NDC,,,,,,outpatient,facility,30,UN,4.98,4.98,0.4,548.68,,3.53,,,percent of total billed charges,,,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.98,,,percent of total billed charges,,,3.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.82,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.98,,,fee schedule,,,4.98,,,percent of total billed charges,,,,,,,,,4.98,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.55,,,percent of total billed charges,,,,,,,,,,,,,,,2.69,,,percent of total billed charges,,,2.59,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,,,,,,,2.94,,,percent of total billed charges,,,548.68,,,per diem,,,4.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.98,,,percent of total billed charges,,,4.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,,,,,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,4.98,,,percent of total billed charges,,,4.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.4,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,,,,,,,4.63,,,percent of total billed charges,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,4.63,,,percent of total billed charges,,,4.63,,,percent of total billed charges,,,3.74,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,,,,,,,3.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.93,,,percent of total billed charges,,
LISINOPRIL 30 MG TAB,2500012935,CDM,637,RC,6818098201,NDC,999,EAPG,,,,outpatient,facility,30,UN,4.98,4.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LITHIUM CARBONATE 150 MG CAP,2500012940,CDM,637,RC,54852625,NDC,,,,,,inpatient,facility,150,UN,0.62,0.62,0.05,0.62,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,
LITHIUM CARBONATE 150 MG CAP,2500012940,CDM,637,RC,54852625,NDC,,,,,,outpatient,facility,150,UN,0.62,0.62,0.05,548.68,,0.44,,,percent of total billed charges,,,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.62,,,percent of total billed charges,,,0.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.62,,,fee schedule,,,0.62,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,0.37,,,percent of total billed charges,,,548.68,,,per diem,,,0.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.62,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.37,,,percent of total billed charges,,
LITHIUM CARBONATE 150 MG CAP,2500012940,CDM,637,RC,54852625,NDC,999,EAPG,,,,outpatient,facility,150,UN,0.62,0.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LITHIUM CARBONATE 300 MG CAP,2500012941,CDM,637,RC,54852725,NDC,,,,,,inpatient,facility,300,UN,1.22,1.22,0.1,1.22,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,
LITHIUM CARBONATE 300 MG CAP,2500012941,CDM,637,RC,54852725,NDC,,,,,,outpatient,facility,300,UN,1.22,1.22,0.1,548.68,,0.87,,,percent of total billed charges,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.22,,,percent of total billed charges,,,0.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.45,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.22,,,fee schedule,,,1.22,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,0.72,,,percent of total billed charges,,,548.68,,,per diem,,,1.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.22,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,0.45,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.72,,,percent of total billed charges,,
LITHIUM CARBONATE 300 MG CAP,2500012941,CDM,637,RC,54852725,NDC,999,EAPG,,,,outpatient,facility,300,UN,1.22,1.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LITHIUM CARBONATE 300 MG TAB,2500012943,CDM,637,RC,54852825,NDC,,,,,,inpatient,facility,300,UN,1.12,1.12,0.09,1.12,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,1.12,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,
LITHIUM CARBONATE 300 MG TAB,2500012943,CDM,637,RC,54852825,NDC,,,,,,outpatient,facility,300,UN,1.12,1.12,0.09,548.68,,0.79,,,percent of total billed charges,,,0.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.12,,,percent of total billed charges,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.41,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.12,,,fee schedule,,,1.12,,,percent of total billed charges,,,,,,,,,1.12,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,548.68,,,per diem,,,1.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.12,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,0.41,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,,,,,,,1.12,,,percent of total billed charges,,,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.66,,,percent of total billed charges,,
LITHIUM CARBONATE 300 MG TAB,2500012943,CDM,637,RC,54852825,NDC,999,EAPG,,,,outpatient,facility,300,UN,1.12,1.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LITHIUM CARBONATE 450 MG TABCR,2500012945,CDM,637,RC,5107914220,NDC,,,,,,inpatient,facility,450,UN,2.51,2.51,0.2,2.51,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,2.51,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,
LITHIUM CARBONATE 450 MG TABCR,2500012945,CDM,637,RC,5107914220,NDC,,,,,,outpatient,facility,450,UN,2.51,2.51,0.2,548.68,,1.78,,,percent of total billed charges,,,0.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.51,,,percent of total billed charges,,,1.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.92,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.51,,,fee schedule,,,2.51,,,percent of total billed charges,,,,,,,,,2.51,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,1.48,,,percent of total billed charges,,,548.68,,,per diem,,,2.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.51,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,0.93,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,2.51,,,percent of total billed charges,,,2.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.48,,,percent of total billed charges,,
LITHIUM CARBONATE 450 MG TABCR,2500012945,CDM,637,RC,5107914220,NDC,999,EAPG,,,,outpatient,facility,450,UN,2.51,2.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LITHIUM CARBONATE SR 300MG TAB,2500012960,CDM,637,RC,6808464001,NDC,,,,,,inpatient,facility,300,UN,1.58,1.58,0.13,1.58,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,1.58,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,
LITHIUM CARBONATE SR 300MG TAB,2500012960,CDM,637,RC,6808464001,NDC,,,,,,outpatient,facility,300,UN,1.58,1.58,0.13,548.68,,1.12,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.58,,,percent of total billed charges,,,0.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.58,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.58,,,fee schedule,,,1.58,,,percent of total billed charges,,,,,,,,,1.58,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,0.93,,,percent of total billed charges,,,548.68,,,per diem,,,1.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.58,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,,,,,,,1.58,,,percent of total billed charges,,,1.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.93,,,percent of total billed charges,,
LITHIUM CARBONATE SR 300MG TAB,2500012960,CDM,637,RC,6808464001,NDC,999,EAPG,,,,outpatient,facility,300,UN,1.58,1.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LOPERAMIDE  2 MG CAP,2500012982,CDM,637,RC,6068722901,NDC,,,,,,inpatient,facility,2,UN,3.36,3.36,0.27,3.36,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,3.36,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,
LOPERAMIDE  2 MG CAP,2500012982,CDM,637,RC,6068722901,NDC,,,,,,outpatient,facility,2,UN,3.36,3.36,0.27,548.68,,2.38,,,percent of total billed charges,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.36,,,percent of total billed charges,,,2.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.36,,,fee schedule,,,3.36,,,percent of total billed charges,,,,,,,,,3.36,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,1.98,,,percent of total billed charges,,,548.68,,,per diem,,,3.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.36,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.27,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,1.24,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,,,,,,,3.36,,,percent of total billed charges,,,3.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.27,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.98,,,percent of total billed charges,,
LOPERAMIDE  2 MG CAP,2500012982,CDM,637,RC,6068722901,NDC,999,EAPG,,,,outpatient,facility,2,UN,3.36,3.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIOTHYRONINE SODIUM 5 MCG TAB,2500012984,CDM,637,RC,5186232001,NDC,,,,,,inpatient,facility,5,UN,6.23,6.23,0.5,6.23,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,6.23,,,percent of total billed charges,,,3.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.74,,,percent of total billed charges,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,5.3,,,percent of total billed charges,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.67,,,percent of total billed charges,,
LIOTHYRONINE SODIUM 5 MCG TAB,2500012984,CDM,637,RC,5186232001,NDC,,,,,,outpatient,facility,5,UN,6.23,6.23,0.5,548.68,,4.42,,,percent of total billed charges,,,1.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.23,,,percent of total billed charges,,,3.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.28,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.23,,,fee schedule,,,6.23,,,percent of total billed charges,,,,,,,,,6.23,,,percent of total billed charges,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.44,,,percent of total billed charges,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,3.68,,,percent of total billed charges,,,548.68,,,per diem,,,6.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.23,,,percent of total billed charges,,,5.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.2,,,percent of total billed charges,,,5.04,,,percent of total billed charges,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,6.23,,,percent of total billed charges,,,6.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.5,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,5.8,,,percent of total billed charges,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,4.67,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.67,,,percent of total billed charges,,
LIOTHYRONINE SODIUM 5 MCG TAB,2500012984,CDM,637,RC,5186232001,NDC,999,EAPG,,,,outpatient,facility,5,UN,6.23,6.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LOPERAMIDE 1 MG/5 ML 10 ML UDC,2500012986,CDM,637,RC,1785661801,NDC,,,,,,inpatient,facility,10,UN,10.46,10.46,0.84,10.46,,,,,,,,,,,,,,10.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.46,,,percent of total billed charges,,,,,,,,,10.46,,,percent of total billed charges,,,5.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.28,,,percent of total billed charges,,,,,,,,,,,,,,,10.46,,,percent of total billed charges,,,8.89,,,percent of total billed charges,,,,,,,,,,,,,,,10.46,,,percent of total billed charges,,,5.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,10.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.16,,,percent of total billed charges,,
LOPERAMIDE 1 MG/5 ML 10 ML UDC,2500012986,CDM,637,RC,1785661801,NDC,,,,,,outpatient,facility,10,UN,10.46,10.46,0.84,548.68,,7.42,,,percent of total billed charges,,,2.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.46,,,percent of total billed charges,,,6.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.83,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.46,,,fee schedule,,,10.46,,,percent of total billed charges,,,,,,,,,10.46,,,percent of total billed charges,,,6.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.45,,,percent of total billed charges,,,,,,,,,,,,,,,5.65,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,5.75,,,percent of total billed charges,,,,,,,,,6.17,,,percent of total billed charges,,,548.68,,,per diem,,,10.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.46,,,percent of total billed charges,,,8.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.56,,,percent of total billed charges,,,10.46,,,percent of total billed charges,,,10.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.06,,,percent of total billed charges,,,8.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.18,,,percent of total billed charges,,,,,,,,,3.87,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,10.46,,,percent of total billed charges,,,10.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.84,,,percent of total billed charges,,,10.46,,,percent of total billed charges,,,,,,,,,,,,,,,10.46,,,percent of total billed charges,,,10.46,,,percent of total billed charges,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,10.46,,,percent of total billed charges,,,10.46,,,percent of total billed charges,,,10.46,,,percent of total billed charges,,,,,,,,,7.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.16,,,percent of total billed charges,,
LOPERAMIDE 1 MG/5 ML 10 ML UDC,2500012986,CDM,637,RC,1785661801,NDC,999,EAPG,,,,outpatient,facility,10,UN,10.46,10.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LORATADINE 10 MG TAB,2500013010,CDM,637,RC,5002442903,NDC,,,,,,inpatient,facility,10,UN,1.78,1.78,0.14,1.78,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,1.78,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,
LORATADINE 10 MG TAB,2500013010,CDM,637,RC,5002442903,NDC,,,,,,outpatient,facility,10,UN,1.78,1.78,0.14,548.68,,1.26,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.78,,,percent of total billed charges,,,1.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.78,,,fee schedule,,,1.78,,,percent of total billed charges,,,,,,,,,1.78,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,1.05,,,percent of total billed charges,,,548.68,,,per diem,,,1.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.78,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,1.78,,,percent of total billed charges,,,1.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.14,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.05,,,percent of total billed charges,,
LORATADINE 10 MG TAB,2500013010,CDM,637,RC,5002442903,NDC,999,EAPG,,,,outpatient,facility,10,UN,1.78,1.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LORATADINE 5 MG LIQUID,2500013011,CDM,637,RC,5167221318,NDC,,,,,,inpatient,facility,5,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
LORATADINE 5 MG LIQUID,2500013011,CDM,637,RC,5167221318,NDC,,,,,,outpatient,facility,5,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
LORATADINE 5 MG LIQUID,2500013011,CDM,637,RC,5167221318,NDC,999,EAPG,,,,outpatient,facility,5,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LORAZEPAM 0.5 MG TAB,2500013030,CDM,637,RC,6931590401,NDC,,,,,,inpatient,facility,0.5,UN,2.11,2.11,0.17,2.11,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,2.11,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,
LORAZEPAM 0.5 MG TAB,2500013030,CDM,637,RC,6931590401,NDC,,,,,,outpatient,facility,0.5,UN,2.11,2.11,0.17,548.68,,1.5,,,percent of total billed charges,,,0.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.11,,,percent of total billed charges,,,1.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.77,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.11,,,fee schedule,,,2.11,,,percent of total billed charges,,,,,,,,,2.11,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,1.24,,,percent of total billed charges,,,548.68,,,per diem,,,2.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.11,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,0.78,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,2.11,,,percent of total billed charges,,,2.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.24,,,percent of total billed charges,,
LORAZEPAM 0.5 MG TAB,2500013030,CDM,637,RC,6931590401,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,2.11,2.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LORAZEPAM 1 MG TAB,2500013031,CDM,637,RC,6931590501,NDC,,,,,,inpatient,facility,1,UN,2.77,2.77,0.22,2.77,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,
LORAZEPAM 1 MG TAB,2500013031,CDM,637,RC,6931590501,NDC,,,,,,outpatient,facility,1,UN,2.77,2.77,0.22,548.68,,1.96,,,percent of total billed charges,,,0.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.77,,,percent of total billed charges,,,1.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.77,,,fee schedule,,,2.77,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,1.63,,,percent of total billed charges,,,548.68,,,per diem,,,2.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.77,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.22,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,2.58,,,percent of total billed charges,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,2.58,,,percent of total billed charges,,,2.58,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.63,,,percent of total billed charges,,
LORAZEPAM 1 MG TAB,2500013031,CDM,637,RC,6931590501,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.77,2.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LORAZEPAM 2 MG/ML 1ML ORAL SYR,2500013033,CDM,637,RC,54353244,NDC,,,,,,inpatient,facility,1,UN,5.28,5.28,0.42,5.28,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,5.28,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,4.49,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.11,,,percent of total billed charges,,
LORAZEPAM 2 MG/ML 1ML ORAL SYR,2500013033,CDM,637,RC,54353244,NDC,,,,,,outpatient,facility,1,UN,5.28,5.28,0.42,548.68,,3.74,,,percent of total billed charges,,,1.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.28,,,percent of total billed charges,,,3.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.93,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.28,,,fee schedule,,,5.28,,,percent of total billed charges,,,,,,,,,5.28,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,3.12,,,percent of total billed charges,,,548.68,,,per diem,,,5.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.28,,,percent of total billed charges,,,4.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,4.27,,,percent of total billed charges,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,5.28,,,percent of total billed charges,,,5.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.42,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,3.96,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,3.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.11,,,percent of total billed charges,,
LORAZEPAM 2 MG/ML 1ML ORAL SYR,2500013033,CDM,637,RC,54353244,NDC,999,EAPG,,,,outpatient,facility,1,UN,5.28,5.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LOSARTAN POTASSIUM 25 MG TAB,2500013050,CDM,637,RC,904704761,NDC,,,,,,inpatient,facility,25,UN,1.91,1.91,0.15,1.91,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,1.91,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,
LOSARTAN POTASSIUM 25 MG TAB,2500013050,CDM,637,RC,904704761,NDC,,,,,,outpatient,facility,25,UN,1.91,1.91,0.15,548.68,,1.35,,,percent of total billed charges,,,0.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.91,,,percent of total billed charges,,,1.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.7,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.91,,,fee schedule,,,1.91,,,percent of total billed charges,,,,,,,,,1.91,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,1.13,,,percent of total billed charges,,,548.68,,,per diem,,,1.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.91,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,0.71,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,1.91,,,percent of total billed charges,,,1.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.13,,,percent of total billed charges,,
LOSARTAN POTASSIUM 25 MG TAB,2500013050,CDM,637,RC,904704761,NDC,999,EAPG,,,,outpatient,facility,25,UN,1.91,1.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LOSARTAN POTASSIUM 50 MG TAB,2500013052,CDM,637,RC,904704861,NDC,,,,,,inpatient,facility,50,UN,2.24,2.24,0.18,2.24,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,
LOSARTAN POTASSIUM 50 MG TAB,2500013052,CDM,637,RC,904704861,NDC,,,,,,outpatient,facility,50,UN,2.24,2.24,0.18,548.68,,1.59,,,percent of total billed charges,,,0.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.24,,,percent of total billed charges,,,1.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.82,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.24,,,fee schedule,,,2.24,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,548.68,,,per diem,,,2.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.24,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.32,,,percent of total billed charges,,
LOSARTAN POTASSIUM 50 MG TAB,2500013052,CDM,637,RC,904704861,NDC,999,EAPG,,,,outpatient,facility,50,UN,2.24,2.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LOXAPINE SUCC 5 MG CAP,2500013073,CDM,637,RC,591036901,NDC,,,,,,inpatient,facility,5,UN,3.26,3.26,0.26,3.26,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,,,,,,,3.26,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,
LOXAPINE SUCC 5 MG CAP,2500013073,CDM,637,RC,591036901,NDC,,,,,,outpatient,facility,5,UN,3.26,3.26,0.26,548.68,,2.31,,,percent of total billed charges,,,0.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.26,,,percent of total billed charges,,,2.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.19,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.26,,,fee schedule,,,3.26,,,percent of total billed charges,,,,,,,,,3.26,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,1.92,,,percent of total billed charges,,,548.68,,,per diem,,,3.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.26,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.2,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,1.21,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,3.26,,,percent of total billed charges,,,3.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,,,,,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,,,,,,,2.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.92,,,percent of total billed charges,,
LOXAPINE SUCC 5 MG CAP,2500013073,CDM,637,RC,591036901,NDC,999,EAPG,,,,outpatient,facility,5,UN,3.26,3.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LURASIDONE 40 MG TAB,2500013094,CDM,637,RC,6340230430,NDC,,,,,,inpatient,facility,40,UN,156.05,156.05,12.48,156.05,,,,,,,,,,,,,,156.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.05,,,percent of total billed charges,,,,,,,,,156.05,,,percent of total billed charges,,,79.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.63,,,percent of total billed charges,,,,,,,,,,,,,,,156.05,,,percent of total billed charges,,,132.64,,,percent of total billed charges,,,,,,,,,,,,,,,156.05,,,percent of total billed charges,,,82.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,156.05,,,percent of total billed charges,,,,,,,,,,,,,,,12.48,,,percent of total billed charges,,,156.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,156.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.94,,,percent of total billed charges,,
LURASIDONE 40 MG TAB,2500013094,CDM,637,RC,6340230430,NDC,,,,,,outpatient,facility,40,UN,156.05,156.05,12.48,548.68,,110.66,,,percent of total billed charges,,,38.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,156.05,,,percent of total billed charges,,,97.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,109.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,109.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,156.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,57.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,156.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,156.05,,,fee schedule,,,156.05,,,percent of total billed charges,,,,,,,,,156.05,,,percent of total billed charges,,,95.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.19,,,percent of total billed charges,,,,,,,,,,,,,,,84.27,,,percent of total billed charges,,,81.15,,,percent of total billed charges,,,85.83,,,percent of total billed charges,,,,,,,,,92.07,,,percent of total billed charges,,,548.68,,,per diem,,,156.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,156.05,,,percent of total billed charges,,,132.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.88,,,percent of total billed charges,,,156.05,,,percent of total billed charges,,,156.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.27,,,percent of total billed charges,,,126.28,,,percent of total billed charges,,,,,,,,,,,,,,,62.42,,,percent of total billed charges,,,,,,,,,57.74,,,percent of total billed charges,,,57.74,,,percent of total billed charges,,,,,,,,,156.05,,,percent of total billed charges,,,156.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,156.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.48,,,percent of total billed charges,,,156.05,,,percent of total billed charges,,,,,,,,,,,,,,,156.05,,,percent of total billed charges,,,156.05,,,percent of total billed charges,,,,,,,,,145.16,,,percent of total billed charges,,,,,,,,,,,,,,,145.16,,,percent of total billed charges,,,145.16,,,percent of total billed charges,,,145.16,,,percent of total billed charges,,,117.04,,,percent of total billed charges,,,156.05,,,percent of total billed charges,,,156.05,,,percent of total billed charges,,,156.05,,,percent of total billed charges,,,,,,,,,109.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.03,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,91.94,,,percent of total billed charges,,
LURASIDONE 40 MG TAB,2500013094,CDM,637,RC,6340230430,NDC,999,EAPG,,,,outpatient,facility,40,UN,156.05,156.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAALOX PLUS  30 ML,2500013125,CDM,637,RC,121176130,NDC,,,,,,inpatient,facility,30,UN,5.96,5.96,0.48,5.96,,,,,,,,,,,,,,5.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.96,,,percent of total billed charges,,,,,,,,,5.96,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,5.96,,,percent of total billed charges,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,5.96,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,5.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,
MAALOX PLUS  30 ML,2500013125,CDM,637,RC,121176130,NDC,,,,,,outpatient,facility,30,UN,5.96,5.96,0.48,548.68,,4.23,,,percent of total billed charges,,,1.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.96,,,percent of total billed charges,,,3.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.96,,,fee schedule,,,5.96,,,percent of total billed charges,,,,,,,,,5.96,,,percent of total billed charges,,,3.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.25,,,percent of total billed charges,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,3.28,,,percent of total billed charges,,,,,,,,,3.52,,,percent of total billed charges,,,548.68,,,per diem,,,5.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.96,,,percent of total billed charges,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,5.96,,,percent of total billed charges,,,5.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.02,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,5.96,,,percent of total billed charges,,,5.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.48,,,percent of total billed charges,,,5.96,,,percent of total billed charges,,,,,,,,,,,,,,,5.96,,,percent of total billed charges,,,5.96,,,percent of total billed charges,,,,,,,,,5.54,,,percent of total billed charges,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,4.47,,,percent of total billed charges,,,5.96,,,percent of total billed charges,,,5.96,,,percent of total billed charges,,,5.96,,,percent of total billed charges,,,,,,,,,4.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.51,,,percent of total billed charges,,
MAALOX PLUS  30 ML,2500013125,CDM,637,RC,121176130,NDC,999,EAPG,,,,outpatient,facility,30,UN,5.96,5.96,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAGNESIUM CHLOR 64 MG TABEC,2500013180,CDM,637,RC,,,,,,,,inpatient,facility,64,UN,1.49,1.49,0.12,1.49,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,1.49,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,
MAGNESIUM CHLOR 64 MG TABEC,2500013180,CDM,637,RC,,,,,,,,outpatient,facility,64,UN,1.49,1.49,0.12,548.68,,1.06,,,percent of total billed charges,,,0.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.49,,,percent of total billed charges,,,0.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.55,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.49,,,fee schedule,,,1.49,,,percent of total billed charges,,,,,,,,,1.49,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,0.88,,,percent of total billed charges,,,548.68,,,per diem,,,1.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.49,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,,,,,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,,,,,,,1.49,,,percent of total billed charges,,,1.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.88,,,percent of total billed charges,,
MAGNESIUM CHLOR 64 MG TABEC,2500013180,CDM,637,RC,999,EAPG,,,,,,outpatient,facility,64,UN,1.49,1.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAGNESIUM CITRATE 300 ML,2500013190,CDM,637,RC,904678744,NDC,,,,,,inpatient,facility,300,UN,3.17,3.17,0.25,3.17,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,2.69,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,
MAGNESIUM CITRATE 300 ML,2500013190,CDM,637,RC,904678744,NDC,,,,,,outpatient,facility,300,UN,3.17,3.17,0.25,548.68,,2.25,,,percent of total billed charges,,,0.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.17,,,percent of total billed charges,,,1.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.16,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.17,,,fee schedule,,,3.17,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,1.87,,,percent of total billed charges,,,548.68,,,per diem,,,3.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.17,,,percent of total billed charges,,,2.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,1.17,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.25,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,2.95,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,2.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.87,,,percent of total billed charges,,
MAGNESIUM CITRATE 300 ML,2500013190,CDM,637,RC,904678744,NDC,999,EAPG,,,,outpatient,facility,300,UN,3.17,3.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAGNESIUM HYDR SUSP 30 ML UDC,2500013210,CDM,637,RC,904684673,NDC,,,,,,inpatient,facility,30,UN,2.55,2.55,0.2,2.55,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,2.55,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,
MAGNESIUM HYDR SUSP 30 ML UDC,2500013210,CDM,637,RC,904684673,NDC,,,,,,outpatient,facility,30,UN,2.55,2.55,0.2,548.68,,1.81,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.55,,,percent of total billed charges,,,1.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.93,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.55,,,fee schedule,,,2.55,,,percent of total billed charges,,,,,,,,,2.55,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,,,,,,,1.5,,,percent of total billed charges,,,548.68,,,per diem,,,2.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.55,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,0.94,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,,,,,,,2.55,,,percent of total billed charges,,,2.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,2.37,,,percent of total billed charges,,,,,,,,,,,,,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,2.37,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.5,,,percent of total billed charges,,
MAGNESIUM HYDR SUSP 30 ML UDC,2500013210,CDM,637,RC,904684673,NDC,999,EAPG,,,,outpatient,facility,30,UN,2.55,2.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MAGNESIUM OXIDE 400 MG TAB,2500013222,CDM,637,RC,1000670028,NDC,,,,,,inpatient,facility,400,UN,1.84,1.84,0.15,1.84,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,1.84,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,
MAGNESIUM OXIDE 400 MG TAB,2500013222,CDM,637,RC,1000670028,NDC,,,,,,outpatient,facility,400,UN,1.84,1.84,0.15,548.68,,1.3,,,percent of total billed charges,,,0.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.84,,,percent of total billed charges,,,1.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.67,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.84,,,fee schedule,,,1.84,,,percent of total billed charges,,,,,,,,,1.84,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,548.68,,,per diem,,,1.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.84,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,1.84,,,percent of total billed charges,,,1.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.08,,,percent of total billed charges,,
MAGNESIUM OXIDE 400 MG TAB,2500013222,CDM,637,RC,1000670028,NDC,999,EAPG,,,,outpatient,facility,400,UN,1.84,1.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MANNITOL 20  500 ML,2500013242,CDM,250,RC,J2150,HCPCS,990771503,NDC,,,,inpatient,facility,500,UN,62.87,62.87,5.03,62.87,,,,,,,,,,,,,,62.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.87,,,percent of total billed charges,,,,,,,,,62.87,,,percent of total billed charges,,,32.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.72,,,percent of total billed charges,,,,,,,,,,,,,,,62.87,,,percent of total billed charges,,,53.44,,,percent of total billed charges,,,,,,,,,,,,,,,62.87,,,percent of total billed charges,,,33.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,62.87,,,percent of total billed charges,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,62.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.04,,,percent of total billed charges,,
MANNITOL 20  500 ML,2500013242,CDM,250,RC,J2150,HCPCS,990771503,NDC,,,,outpatient,facility,500,UN,62.87,62.87,1.07,548.68,,44.58,,,percent of total billed charges,,,15.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,62.87,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,62.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,23.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.07,,,fee schedule,,,62.87,,,fee schedule,,,62.87,,,percent of total billed charges,,,,,,,,,62.87,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,37.09,,,percent of total billed charges,,,548.68,,,per diem,,,62.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,62.87,,,percent of total billed charges,,,53.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.39,,,percent of total billed charges,,,62.87,,,percent of total billed charges,,,62.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.41,,,percent of total billed charges,,,50.87,,,percent of total billed charges,,,,,,,,,,,,,,,25.15,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,62.87,,,percent of total billed charges,,,62.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,62.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.03,,,percent of total billed charges,,,62.87,,,percent of total billed charges,,,,,,,,,,,,,,,62.87,,,percent of total billed charges,,,62.87,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3,,,fee schedule,,,62.87,,,percent of total billed charges,,,62.87,,,percent of total billed charges,,,62.87,,,percent of total billed charges,,,,,,,,,44.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,37.04,,,percent of total billed charges,,
MANNITOL 20  500 ML,2500013242,CDM,250,RC,J2150,HCPCS,990771503,NDC,496,EAPG,,outpatient,facility,500,UN,62.87,62.87,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEDROXYPROGESTERONE 2.5 MG TAB,2500013322,CDM,637,RC,555087202,NDC,,,,,,inpatient,facility,2.5,UN,1.02,1.02,0.08,1.02,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,
MEDROXYPROGESTERONE 2.5 MG TAB,2500013322,CDM,637,RC,555087202,NDC,,,,,,outpatient,facility,2.5,UN,1.02,1.02,0.08,548.68,,0.72,,,percent of total billed charges,,,0.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.02,,,percent of total billed charges,,,0.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.37,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.02,,,fee schedule,,,1.02,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.6,,,percent of total billed charges,,,548.68,,,per diem,,,1.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.02,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,0.38,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.6,,,percent of total billed charges,,
MEDROXYPROGESTERONE 2.5 MG TAB,2500013322,CDM,637,RC,555087202,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,1.02,1.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEGESTROL ACETATE 20 MG TAB,2500013352,CDM,637,RC,555060602,NDC,,,,,,inpatient,facility,20,UN,3.43,3.43,0.27,3.43,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,3.43,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,2.92,,,percent of total billed charges,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,
MEGESTROL ACETATE 20 MG TAB,2500013352,CDM,637,RC,555060602,NDC,,,,,,outpatient,facility,20,UN,3.43,3.43,0.27,548.68,,2.43,,,percent of total billed charges,,,0.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.43,,,percent of total billed charges,,,2.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.26,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.43,,,fee schedule,,,3.43,,,percent of total billed charges,,,,,,,,,3.43,,,percent of total billed charges,,,2.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.44,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,,,,,,,2.02,,,percent of total billed charges,,,548.68,,,per diem,,,3.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.43,,,percent of total billed charges,,,2.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,2.78,,,percent of total billed charges,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,1.27,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,,,,,,,3.43,,,percent of total billed charges,,,3.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.27,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,3.43,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,3.19,,,percent of total billed charges,,,3.19,,,percent of total billed charges,,,3.19,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,2.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.02,,,percent of total billed charges,,
MEGESTROL ACETATE 20 MG TAB,2500013352,CDM,637,RC,555060602,NDC,999,EAPG,,,,outpatient,facility,20,UN,3.43,3.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEGESTROL SUS 400 MG/10 ML UDC,2500013358,CDM,637,RC,121477640,NDC,,,,,,inpatient,facility,10,UN,14.95,14.95,1.2,14.95,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,,,,,,,14.95,,,percent of total billed charges,,,7.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.97,,,percent of total billed charges,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,12.71,,,percent of total billed charges,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,7.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,
MEGESTROL SUS 400 MG/10 ML UDC,2500013358,CDM,637,RC,121477640,NDC,,,,,,outpatient,facility,10,UN,14.95,14.95,1.2,548.68,,10.6,,,percent of total billed charges,,,3.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.95,,,percent of total billed charges,,,9.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.47,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.95,,,fee schedule,,,14.95,,,percent of total billed charges,,,,,,,,,14.95,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.65,,,percent of total billed charges,,,,,,,,,,,,,,,8.07,,,percent of total billed charges,,,7.77,,,percent of total billed charges,,,8.22,,,percent of total billed charges,,,,,,,,,8.82,,,percent of total billed charges,,,548.68,,,per diem,,,14.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.95,,,percent of total billed charges,,,12.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.94,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.09,,,percent of total billed charges,,,12.1,,,percent of total billed charges,,,,,,,,,,,,,,,5.98,,,percent of total billed charges,,,,,,,,,5.53,,,percent of total billed charges,,,5.53,,,percent of total billed charges,,,,,,,,,14.95,,,percent of total billed charges,,,14.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.2,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,14.95,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,,,,,,,13.91,,,percent of total billed charges,,,,,,,,,,,,,,,13.91,,,percent of total billed charges,,,13.91,,,percent of total billed charges,,,13.91,,,percent of total billed charges,,,11.21,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,,,,,,,10.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.81,,,percent of total billed charges,,
MEGESTROL SUS 400 MG/10 ML UDC,2500013358,CDM,637,RC,121477640,NDC,999,EAPG,,,,outpatient,facility,10,UN,14.95,14.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MELOXICAM 7.5 MG TAB,2500013366,CDM,637,RC,5026852515,NDC,,,,,,inpatient,facility,7.5,UN,10.23,10.23,0.82,10.23,,,,,,,,,,,,,,10.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.23,,,percent of total billed charges,,,,,,,,,10.23,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,10.23,,,percent of total billed charges,,,8.7,,,percent of total billed charges,,,,,,,,,,,,,,,10.23,,,percent of total billed charges,,,5.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,10.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.03,,,percent of total billed charges,,
MELOXICAM 7.5 MG TAB,2500013366,CDM,637,RC,5026852515,NDC,,,,,,outpatient,facility,7.5,UN,10.23,10.23,0.82,548.68,,7.25,,,percent of total billed charges,,,2.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.23,,,percent of total billed charges,,,6.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.23,,,fee schedule,,,10.23,,,percent of total billed charges,,,,,,,,,10.23,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,5.52,,,percent of total billed charges,,,5.32,,,percent of total billed charges,,,5.63,,,percent of total billed charges,,,,,,,,,6.04,,,percent of total billed charges,,,548.68,,,per diem,,,10.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.23,,,percent of total billed charges,,,8.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.43,,,percent of total billed charges,,,10.23,,,percent of total billed charges,,,10.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.9,,,percent of total billed charges,,,8.28,,,percent of total billed charges,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,,,,3.79,,,percent of total billed charges,,,3.79,,,percent of total billed charges,,,,,,,,,10.23,,,percent of total billed charges,,,10.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.82,,,percent of total billed charges,,,10.23,,,percent of total billed charges,,,,,,,,,,,,,,,10.23,,,percent of total billed charges,,,10.23,,,percent of total billed charges,,,,,,,,,9.52,,,percent of total billed charges,,,,,,,,,,,,,,,9.52,,,percent of total billed charges,,,9.52,,,percent of total billed charges,,,9.52,,,percent of total billed charges,,,7.67,,,percent of total billed charges,,,10.23,,,percent of total billed charges,,,10.23,,,percent of total billed charges,,,10.23,,,percent of total billed charges,,,,,,,,,7.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.03,,,percent of total billed charges,,
MELOXICAM 7.5 MG TAB,2500013366,CDM,637,RC,5026852515,NDC,999,EAPG,,,,outpatient,facility,7.5,UN,10.23,10.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MENTHOL/METHYL SALIC OINT 30GM,2500013370,CDM,637,RC,5416255501,NDC,,,,,,inpatient,facility,30,UN,2.85,2.85,0.23,2.85,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,2.85,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,
MENTHOL/METHYL SALIC OINT 30GM,2500013370,CDM,637,RC,5416255501,NDC,,,,,,outpatient,facility,30,UN,2.85,2.85,0.23,548.68,,2.02,,,percent of total billed charges,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.85,,,percent of total billed charges,,,1.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.04,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.85,,,fee schedule,,,2.85,,,percent of total billed charges,,,,,,,,,2.85,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,548.68,,,per diem,,,2.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.85,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,,,,,,,1.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,2.85,,,percent of total billed charges,,,2.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.68,,,percent of total billed charges,,
MENTHOL/METHYL SALIC OINT 30GM,2500013370,CDM,637,RC,5416255501,NDC,999,EAPG,,,,outpatient,facility,30,UN,2.85,2.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MERCAPTOPURINE 50 MG TAB,2500013410,CDM,637,RC,54458111,NDC,,,,,,inpatient,facility,50,UN,26.99,26.99,2.16,26.99,,,,,,,,,,,,,,26.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.99,,,percent of total billed charges,,,,,,,,,26.99,,,percent of total billed charges,,,13.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.19,,,percent of total billed charges,,,,,,,,,,,,,,,26.99,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,26.99,,,percent of total billed charges,,,14.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,26.99,,,percent of total billed charges,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,26.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.9,,,percent of total billed charges,,
MERCAPTOPURINE 50 MG TAB,2500013410,CDM,637,RC,54458111,NDC,,,,,,outpatient,facility,50,UN,26.99,26.99,2.16,548.68,,19.14,,,percent of total billed charges,,,6.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,26.99,,,percent of total billed charges,,,16.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,18.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,18.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,26.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.88,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,26.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,26.99,,,fee schedule,,,26.99,,,percent of total billed charges,,,,,,,,,26.99,,,percent of total billed charges,,,16.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.23,,,percent of total billed charges,,,,,,,,,,,,,,,14.57,,,percent of total billed charges,,,14.03,,,percent of total billed charges,,,14.84,,,percent of total billed charges,,,,,,,,,15.92,,,percent of total billed charges,,,548.68,,,per diem,,,26.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,26.99,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.33,,,percent of total billed charges,,,26.99,,,percent of total billed charges,,,26.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.21,,,percent of total billed charges,,,21.84,,,percent of total billed charges,,,,,,,,,,,,,,,10.8,,,percent of total billed charges,,,,,,,,,9.99,,,percent of total billed charges,,,9.99,,,percent of total billed charges,,,,,,,,,26.99,,,percent of total billed charges,,,26.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.16,,,percent of total billed charges,,,26.99,,,percent of total billed charges,,,,,,,,,,,,,,,26.99,,,percent of total billed charges,,,26.99,,,percent of total billed charges,,,,,,,,,25.11,,,percent of total billed charges,,,,,,,,,,,,,,,25.11,,,percent of total billed charges,,,25.11,,,percent of total billed charges,,,25.11,,,percent of total billed charges,,,20.24,,,percent of total billed charges,,,26.99,,,percent of total billed charges,,,26.99,,,percent of total billed charges,,,26.99,,,percent of total billed charges,,,,,,,,,18.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15.9,,,percent of total billed charges,,
MERCAPTOPURINE 50 MG TAB,2500013410,CDM,637,RC,54458111,NDC,999,EAPG,,,,outpatient,facility,50,UN,26.99,26.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEROPENEM 500 MG VIAL,2500013424,CDM,636,RC,J2185,HCPCS,4456740010,NDC,,,,inpatient,facility,500,UN,138.01,138.01,11.04,138.01,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,138.01,,,percent of total billed charges,,,70.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,117.31,,,percent of total billed charges,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,73.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,11.04,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.32,,,percent of total billed charges,,
MEROPENEM 500 MG VIAL,2500013424,CDM,636,RC,J2185,HCPCS,4456740010,NDC,,,,outpatient,facility,500,UN,138.01,138.01,0.33,548.68,,97.86,,,percent of total billed charges,,,33.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,138.01,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,50.51,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,138.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,138.01,,,fee schedule,,,138.01,,,percent of total billed charges,,,,,,,,,138.01,,,percent of total billed charges,,,84.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,81.43,,,percent of total billed charges,,,548.68,,,per diem,,,138.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,138.01,,,percent of total billed charges,,,117.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73.3,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.1,,,percent of total billed charges,,,111.68,,,percent of total billed charges,,,,,,,,,,,,,,,55.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,138.01,,,percent of total billed charges,,,138.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,138.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.04,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.33,,,fee schedule,,,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,96.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,81.32,,,percent of total billed charges,,
MEROPENEM 500 MG VIAL,2500013424,CDM,636,RC,J2185,HCPCS,4456740010,NDC,496,EAPG,,outpatient,facility,500,UN,138.01,138.01,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESALAMINE 250 MG CAPCR,2500013440,CDM,637,RC,5409218981,NDC,,,,,,inpatient,facility,250,UN,10.03,10.03,0.8,10.03,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,,,,,,,10.03,,,percent of total billed charges,,,5.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,8.53,,,percent of total billed charges,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,5.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.91,,,percent of total billed charges,,
MESALAMINE 250 MG CAPCR,2500013440,CDM,637,RC,5409218981,NDC,,,,,,outpatient,facility,250,UN,10.03,10.03,0.8,548.68,,7.11,,,percent of total billed charges,,,2.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.03,,,percent of total billed charges,,,6.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.67,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.03,,,fee schedule,,,10.03,,,percent of total billed charges,,,,,,,,,10.03,,,percent of total billed charges,,,6.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.15,,,percent of total billed charges,,,,,,,,,,,,,,,5.42,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,5.52,,,percent of total billed charges,,,,,,,,,5.92,,,percent of total billed charges,,,548.68,,,per diem,,,10.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.03,,,percent of total billed charges,,,8.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.33,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.77,,,percent of total billed charges,,,8.12,,,percent of total billed charges,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,,,,,,,,3.71,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,,,,,,,10.03,,,percent of total billed charges,,,10.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.8,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,10.03,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,,,,,,,9.33,,,percent of total billed charges,,,,,,,,,,,,,,,9.33,,,percent of total billed charges,,,9.33,,,percent of total billed charges,,,9.33,,,percent of total billed charges,,,7.52,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.91,,,percent of total billed charges,,
MESALAMINE 250 MG CAPCR,2500013440,CDM,637,RC,5409218981,NDC,999,EAPG,,,,outpatient,facility,250,UN,10.03,10.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESALAMINE 800 MG TABDR,2500013443,CDM,637,RC,6838243528,NDC,,,,,,inpatient,facility,800,UN,30.59,30.59,2.45,30.59,,,,,,,,,,,,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.59,,,percent of total billed charges,,,,,,,,,30.59,,,percent of total billed charges,,,15.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.35,,,percent of total billed charges,,,,,,,,,,,,,,,30.59,,,percent of total billed charges,,,26,,,percent of total billed charges,,,,,,,,,,,,,,,30.59,,,percent of total billed charges,,,16.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.02,,,percent of total billed charges,,
MESALAMINE 800 MG TABDR,2500013443,CDM,637,RC,6838243528,NDC,,,,,,outpatient,facility,800,UN,30.59,30.59,2.45,548.68,,21.69,,,percent of total billed charges,,,7.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,30.59,,,percent of total billed charges,,,19.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,21.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,21.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.2,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,30.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,30.59,,,fee schedule,,,30.59,,,percent of total billed charges,,,,,,,,,30.59,,,percent of total billed charges,,,18.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.8,,,percent of total billed charges,,,,,,,,,,,,,,,16.52,,,percent of total billed charges,,,15.91,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,,,,,,,18.05,,,percent of total billed charges,,,548.68,,,per diem,,,30.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,30.59,,,percent of total billed charges,,,26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.25,,,percent of total billed charges,,,30.59,,,percent of total billed charges,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.64,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,,12.24,,,percent of total billed charges,,,,,,,,,11.32,,,percent of total billed charges,,,11.32,,,percent of total billed charges,,,,,,,,,30.59,,,percent of total billed charges,,,30.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.45,,,percent of total billed charges,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,30.59,,,percent of total billed charges,,,30.59,,,percent of total billed charges,,,,,,,,,28.45,,,percent of total billed charges,,,,,,,,,,,,,,,28.45,,,percent of total billed charges,,,28.45,,,percent of total billed charges,,,28.45,,,percent of total billed charges,,,22.94,,,percent of total billed charges,,,30.59,,,percent of total billed charges,,,30.59,,,percent of total billed charges,,,30.59,,,percent of total billed charges,,,,,,,,,21.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.02,,,percent of total billed charges,,
MESALAMINE 800 MG TABDR,2500013443,CDM,637,RC,6838243528,NDC,999,EAPG,,,,outpatient,facility,800,UN,30.59,30.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESALAMINE 1000 MG SUPP,2500013446,CDM,637,RC,3172200530,NDC,,,,,,inpatient,facility,1000,UN,138.01,138.01,11.04,138.01,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,138.01,,,percent of total billed charges,,,70.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,117.31,,,percent of total billed charges,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,73.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,11.04,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.32,,,percent of total billed charges,,
MESALAMINE 1000 MG SUPP,2500013446,CDM,637,RC,3172200530,NDC,,,,,,outpatient,facility,1000,UN,138.01,138.01,11.04,548.68,,97.86,,,percent of total billed charges,,,33.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,138.01,,,percent of total billed charges,,,86.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,97.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,97.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,50.51,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,138.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,138.01,,,fee schedule,,,138.01,,,percent of total billed charges,,,,,,,,,138.01,,,percent of total billed charges,,,84.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.33,,,percent of total billed charges,,,,,,,,,,,,,,,74.53,,,percent of total billed charges,,,71.77,,,percent of total billed charges,,,75.91,,,percent of total billed charges,,,,,,,,,81.43,,,percent of total billed charges,,,548.68,,,per diem,,,138.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,138.01,,,percent of total billed charges,,,117.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73.3,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.1,,,percent of total billed charges,,,111.68,,,percent of total billed charges,,,,,,,,,,,,,,,55.2,,,percent of total billed charges,,,,,,,,,51.06,,,percent of total billed charges,,,51.06,,,percent of total billed charges,,,,,,,,,138.01,,,percent of total billed charges,,,138.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,138.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.04,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,,,,,,,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,128.38,,,percent of total billed charges,,,,,,,,,,,,,,,128.38,,,percent of total billed charges,,,128.38,,,percent of total billed charges,,,128.38,,,percent of total billed charges,,,103.51,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,138.01,,,percent of total billed charges,,,,,,,,,96.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,81.32,,,percent of total billed charges,,
MESALAMINE 1000 MG SUPP,2500013446,CDM,637,RC,3172200530,NDC,999,EAPG,,,,outpatient,facility,1000,UN,138.01,138.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESALAMINE ENEMA 4 GM/60 ML,2500013449,CDM,637,RC,4580209851,NDC,,,,,,inpatient,facility,60,UN,80.16,80.16,6.41,80.16,,,,,,,,,,,,,,80.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.16,,,percent of total billed charges,,,,,,,,,80.16,,,percent of total billed charges,,,40.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.1,,,percent of total billed charges,,,,,,,,,,,,,,,80.16,,,percent of total billed charges,,,68.14,,,percent of total billed charges,,,,,,,,,,,,,,,80.16,,,percent of total billed charges,,,42.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,80.16,,,percent of total billed charges,,,,,,,,,,,,,,,6.41,,,percent of total billed charges,,,80.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,80.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.23,,,percent of total billed charges,,
MESALAMINE ENEMA 4 GM/60 ML,2500013449,CDM,637,RC,4580209851,NDC,,,,,,outpatient,facility,60,UN,80.16,80.16,6.41,548.68,,56.84,,,percent of total billed charges,,,19.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,80.16,,,percent of total billed charges,,,50.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,56.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,56.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,80.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,29.34,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,80.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,80.16,,,fee schedule,,,80.16,,,percent of total billed charges,,,,,,,,,80.16,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.11,,,percent of total billed charges,,,,,,,,,,,,,,,43.29,,,percent of total billed charges,,,41.68,,,percent of total billed charges,,,44.09,,,percent of total billed charges,,,,,,,,,47.29,,,percent of total billed charges,,,548.68,,,per diem,,,80.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,80.16,,,percent of total billed charges,,,68.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,42.57,,,percent of total billed charges,,,80.16,,,percent of total billed charges,,,80.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.08,,,percent of total billed charges,,,64.87,,,percent of total billed charges,,,,,,,,,,,,,,,32.06,,,percent of total billed charges,,,,,,,,,29.66,,,percent of total billed charges,,,29.66,,,percent of total billed charges,,,,,,,,,80.16,,,percent of total billed charges,,,80.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,80.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.41,,,percent of total billed charges,,,80.16,,,percent of total billed charges,,,,,,,,,,,,,,,80.16,,,percent of total billed charges,,,80.16,,,percent of total billed charges,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,74.56,,,percent of total billed charges,,,74.56,,,percent of total billed charges,,,60.12,,,percent of total billed charges,,,80.16,,,percent of total billed charges,,,80.16,,,percent of total billed charges,,,80.16,,,percent of total billed charges,,,,,,,,,56.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.08,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,47.23,,,percent of total billed charges,,
MESALAMINE ENEMA 4 GM/60 ML,2500013449,CDM,637,RC,4580209851,NDC,999,EAPG,,,,outpatient,facility,60,UN,80.16,80.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METFORMIN HCL 500 MG TAB,2500013490,CDM,637,RC,7278919290,NDC,,,,,,inpatient,facility,500,UN,0.39,0.39,0.03,0.39,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,
METFORMIN HCL 500 MG TAB,2500013490,CDM,637,RC,7278919290,NDC,,,,,,outpatient,facility,500,UN,0.39,0.39,0.03,548.68,,0.28,,,percent of total billed charges,,,0.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.39,,,percent of total billed charges,,,0.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.14,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.39,,,fee schedule,,,0.39,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,548.68,,,per diem,,,0.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.39,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,0.14,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.23,,,percent of total billed charges,,
METFORMIN HCL 500 MG TAB,2500013490,CDM,637,RC,7278919290,NDC,999,EAPG,,,,outpatient,facility,500,UN,0.39,0.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METFORMIN HCL 850 MG TAB,2500013493,CDM,637,RC,3535692290,NDC,,,,,,inpatient,facility,850,UN,4.72,4.72,0.38,4.72,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,4.72,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.83,,,percent of total billed charges,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,4.01,,,percent of total billed charges,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.78,,,percent of total billed charges,,
METFORMIN HCL 850 MG TAB,2500013493,CDM,637,RC,3535692290,NDC,,,,,,outpatient,facility,850,UN,4.72,4.72,0.38,548.68,,3.35,,,percent of total billed charges,,,1.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.72,,,percent of total billed charges,,,2.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.72,,,fee schedule,,,4.72,,,percent of total billed charges,,,,,,,,,4.72,,,percent of total billed charges,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,2.45,,,percent of total billed charges,,,2.6,,,percent of total billed charges,,,,,,,,,2.78,,,percent of total billed charges,,,548.68,,,per diem,,,4.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.72,,,percent of total billed charges,,,4.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.18,,,percent of total billed charges,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,4.72,,,percent of total billed charges,,,4.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.38,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,4.39,,,percent of total billed charges,,,,,,,,,,,,,,,4.39,,,percent of total billed charges,,,4.39,,,percent of total billed charges,,,4.39,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,,,,,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.78,,,percent of total billed charges,,
METFORMIN HCL 850 MG TAB,2500013493,CDM,637,RC,3535692290,NDC,999,EAPG,,,,outpatient,facility,850,UN,4.72,4.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHACHOLINE 100 MG INJ NEB,2500013500,CDM,636,RC,J7674,HCPCS,6428110006,NDC,,,,inpatient,facility,100,UN,273.9,273.9,21.91,273.9,,,,,,,,,,,,,,273.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,273.9,,,percent of total billed charges,,,,,,,,,273.9,,,percent of total billed charges,,,139.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.34,,,percent of total billed charges,,,,,,,,,,,,,,,273.9,,,percent of total billed charges,,,232.81,,,percent of total billed charges,,,,,,,,,,,,,,,273.9,,,percent of total billed charges,,,145.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,273.9,,,percent of total billed charges,,,,,,,,,,,,,,,21.91,,,percent of total billed charges,,,273.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.38,,,percent of total billed charges,,
METHACHOLINE 100 MG INJ NEB,2500013500,CDM,636,RC,J7674,HCPCS,6428110006,NDC,,,,outpatient,facility,100,UN,273.9,273.9,1.54,548.68,,194.22,,,percent of total billed charges,,,66.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,273.9,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,273.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,100.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,273.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,273.9,,,fee schedule,,,273.9,,,percent of total billed charges,,,,,,,,,273.9,,,percent of total billed charges,,,167.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,161.6,,,percent of total billed charges,,,548.68,,,per diem,,,273.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,273.9,,,percent of total billed charges,,,232.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,145.47,,,percent of total billed charges,,,273.9,,,percent of total billed charges,,,273.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.77,,,percent of total billed charges,,,221.64,,,percent of total billed charges,,,,,,,,,,,,,,,109.56,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,273.9,,,percent of total billed charges,,,273.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,273.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.91,,,percent of total billed charges,,,273.9,,,percent of total billed charges,,,,,,,,,,,,,,,273.9,,,percent of total billed charges,,,273.9,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.54,,,fee schedule,,,273.9,,,percent of total billed charges,,,273.9,,,percent of total billed charges,,,273.9,,,percent of total billed charges,,,,,,,,,192.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,161.38,,,percent of total billed charges,,
METHACHOLINE 100 MG INJ NEB,2500013500,CDM,636,RC,J7674,HCPCS,6428110006,NDC,999,EAPG,,outpatient,facility,100,UN,273.9,273.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHADONE ORAL 10 MG TAB,2500013510,CDM,637,RC,904653061,NDC,,,,,,inpatient,facility,10,UN,0.82,0.82,0.07,0.82,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,
METHADONE ORAL 10 MG TAB,2500013510,CDM,637,RC,904653061,NDC,,,,,,outpatient,facility,10,UN,0.82,0.82,0.07,548.68,,0.58,,,percent of total billed charges,,,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.82,,,percent of total billed charges,,,0.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.82,,,fee schedule,,,0.82,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,0.48,,,percent of total billed charges,,,548.68,,,per diem,,,0.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.82,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.48,,,percent of total billed charges,,
METHADONE ORAL 10 MG TAB,2500013510,CDM,637,RC,904653061,NDC,999,EAPG,,,,outpatient,facility,10,UN,0.82,0.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHADONE ORAL 40 MG TAB,2500013511,CDM,637,RC,6668989840,NDC,,,,,,inpatient,facility,40,UN,0.99,0.99,0.08,0.99,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
METHADONE ORAL 40 MG TAB,2500013511,CDM,637,RC,6668989840,NDC,,,,,,outpatient,facility,40,UN,0.99,0.99,0.08,548.68,,0.7,,,percent of total billed charges,,,0.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.99,,,percent of total billed charges,,,0.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.99,,,fee schedule,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,0.58,,,percent of total billed charges,,,548.68,,,per diem,,,0.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.99,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,0.37,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
METHADONE ORAL 40 MG TAB,2500013511,CDM,637,RC,6668989840,NDC,999,EAPG,,,,outpatient,facility,40,UN,0.99,0.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHADONE ORAL 5 MG TAB,2500013512,CDM,637,RC,406575562,NDC,,,,,,inpatient,facility,5,UN,1.51,1.51,0.12,1.51,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,1.51,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,
METHADONE ORAL 5 MG TAB,2500013512,CDM,637,RC,406575562,NDC,,,,,,outpatient,facility,5,UN,1.51,1.51,0.12,548.68,,1.07,,,percent of total billed charges,,,0.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.51,,,percent of total billed charges,,,0.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.55,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.51,,,fee schedule,,,1.51,,,percent of total billed charges,,,,,,,,,1.51,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,0.89,,,percent of total billed charges,,,548.68,,,per diem,,,1.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.51,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,1.51,,,percent of total billed charges,,,1.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.89,,,percent of total billed charges,,
METHADONE ORAL 5 MG TAB,2500013512,CDM,637,RC,406575562,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.51,1.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHENAMINE HIPPURATE 1 GM TAB,2500013540,CDM,637,RC,6586278201,NDC,,,,,,inpatient,facility,1,UN,6.9,6.9,0.55,6.9,,,,,,,,,,,,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.9,,,percent of total billed charges,,,,,,,,,6.9,,,percent of total billed charges,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.14,,,percent of total billed charges,,,,,,,,,,,,,,,6.9,,,percent of total billed charges,,,5.86,,,percent of total billed charges,,,,,,,,,,,,,,,6.9,,,percent of total billed charges,,,3.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.07,,,percent of total billed charges,,
METHENAMINE HIPPURATE 1 GM TAB,2500013540,CDM,637,RC,6586278201,NDC,,,,,,outpatient,facility,1,UN,6.9,6.9,0.55,548.68,,4.89,,,percent of total billed charges,,,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.9,,,percent of total billed charges,,,4.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.53,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.9,,,fee schedule,,,6.9,,,percent of total billed charges,,,,,,,,,6.9,,,percent of total billed charges,,,4.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,3.73,,,percent of total billed charges,,,3.59,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,4.07,,,percent of total billed charges,,,548.68,,,per diem,,,6.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.9,,,percent of total billed charges,,,5.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.66,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,5.58,,,percent of total billed charges,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,,,,,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,6.9,,,percent of total billed charges,,,6.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.55,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,,,,,,,,,,,,,6.9,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,,,,,,,6.42,,,percent of total billed charges,,,,,,,,,,,,,,,6.42,,,percent of total billed charges,,,6.42,,,percent of total billed charges,,,6.42,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,6.9,,,percent of total billed charges,,,,,,,,,4.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.07,,,percent of total billed charges,,
METHENAMINE HIPPURATE 1 GM TAB,2500013540,CDM,637,RC,6586278201,NDC,999,EAPG,,,,outpatient,facility,1,UN,6.9,6.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHIMAZOLE 5 MG TAB,2500013562,CDM,637,RC,2315507001,NDC,,,,,,inpatient,facility,5,UN,1.45,1.45,0.12,1.45,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,
METHIMAZOLE 5 MG TAB,2500013562,CDM,637,RC,2315507001,NDC,,,,,,outpatient,facility,5,UN,1.45,1.45,0.12,548.68,,1.03,,,percent of total billed charges,,,0.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.45,,,percent of total billed charges,,,0.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.53,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.45,,,fee schedule,,,1.45,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,0.86,,,percent of total billed charges,,,548.68,,,per diem,,,1.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.45,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,0.54,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,1.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.85,,,percent of total billed charges,,
METHIMAZOLE 5 MG TAB,2500013562,CDM,637,RC,2315507001,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.45,1.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHOCARBAMOL 500 MG TAB,2500013572,CDM,637,RC,7001075401,NDC,,,,,,inpatient,facility,500,UN,1.68,1.68,0.13,1.68,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,
METHOCARBAMOL 500 MG TAB,2500013572,CDM,637,RC,7001075401,NDC,,,,,,outpatient,facility,500,UN,1.68,1.68,0.13,548.68,,1.19,,,percent of total billed charges,,,0.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.68,,,percent of total billed charges,,,1.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.68,,,fee schedule,,,1.68,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,548.68,,,per diem,,,1.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.68,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.99,,,percent of total billed charges,,
METHOCARBAMOL 500 MG TAB,2500013572,CDM,637,RC,7001075401,NDC,999,EAPG,,,,outpatient,facility,500,UN,1.68,1.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPHENIDATE 10 MG TAB,2500013660,CDM,637,RC,6808482321,NDC,,,,,,inpatient,facility,10,UN,6.56,6.56,0.52,6.56,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,6.56,,,percent of total billed charges,,,3.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.94,,,percent of total billed charges,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,5.58,,,percent of total billed charges,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,3.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,
METHYLPHENIDATE 10 MG TAB,2500013660,CDM,637,RC,6808482321,NDC,,,,,,outpatient,facility,10,UN,6.56,6.56,0.52,548.68,,4.65,,,percent of total billed charges,,,1.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.56,,,percent of total billed charges,,,4.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.56,,,fee schedule,,,6.56,,,percent of total billed charges,,,,,,,,,6.56,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.67,,,percent of total billed charges,,,,,,,,,,,,,,,3.54,,,percent of total billed charges,,,3.41,,,percent of total billed charges,,,3.61,,,percent of total billed charges,,,,,,,,,3.87,,,percent of total billed charges,,,548.68,,,per diem,,,6.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.56,,,percent of total billed charges,,,5.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.48,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.43,,,percent of total billed charges,,,5.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,,,,,,,2.43,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,,,,,,,6.56,,,percent of total billed charges,,,6.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.52,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,6.1,,,percent of total billed charges,,,,,,,,,,,,,,,6.1,,,percent of total billed charges,,,6.1,,,percent of total billed charges,,,6.1,,,percent of total billed charges,,,4.92,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,6.56,,,percent of total billed charges,,,,,,,,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.87,,,percent of total billed charges,,
METHYLPHENIDATE 10 MG TAB,2500013660,CDM,637,RC,6808482321,NDC,999,EAPG,,,,outpatient,facility,10,UN,6.56,6.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPHENIDATE 5 MG TAB,2500013664,CDM,637,RC,1070210001,NDC,,,,,,inpatient,facility,5,UN,2.38,2.38,0.19,2.38,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,2.38,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
METHYLPHENIDATE 5 MG TAB,2500013664,CDM,637,RC,1070210001,NDC,,,,,,outpatient,facility,5,UN,2.38,2.38,0.19,548.68,,1.69,,,percent of total billed charges,,,0.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.38,,,percent of total billed charges,,,1.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.38,,,fee schedule,,,2.38,,,percent of total billed charges,,,,,,,,,2.38,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,548.68,,,per diem,,,2.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.38,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,0.88,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,,,,,,,2.38,,,percent of total billed charges,,,2.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.19,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.4,,,percent of total billed charges,,
METHYLPHENIDATE 5 MG TAB,2500013664,CDM,637,RC,1070210001,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.38,2.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPHENIDATE 18 MG TABCR,2500013666,CDM,637,RC,3172295201,NDC,,,,,,inpatient,facility,18,UN,43.59,43.59,3.49,43.59,,,,,,,,,,,,,,43.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.59,,,percent of total billed charges,,,,,,,,,43.59,,,percent of total billed charges,,,22.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.15,,,percent of total billed charges,,,,,,,,,,,,,,,43.59,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,,,,,,,,,,,,,43.59,,,percent of total billed charges,,,23.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,43.59,,,percent of total billed charges,,,,,,,,,,,,,,,3.49,,,percent of total billed charges,,,43.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.68,,,percent of total billed charges,,
METHYLPHENIDATE 18 MG TABCR,2500013666,CDM,637,RC,3172295201,NDC,,,,,,outpatient,facility,18,UN,43.59,43.59,3.49,548.68,,30.91,,,percent of total billed charges,,,10.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,43.59,,,percent of total billed charges,,,27.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,30.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,30.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,43.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,15.95,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,43.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,43.59,,,fee schedule,,,43.59,,,percent of total billed charges,,,,,,,,,43.59,,,percent of total billed charges,,,26.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.06,,,percent of total billed charges,,,,,,,,,,,,,,,23.54,,,percent of total billed charges,,,22.67,,,percent of total billed charges,,,23.97,,,percent of total billed charges,,,,,,,,,25.72,,,percent of total billed charges,,,548.68,,,per diem,,,43.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,43.59,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.15,,,percent of total billed charges,,,43.59,,,percent of total billed charges,,,43.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.41,,,percent of total billed charges,,,35.27,,,percent of total billed charges,,,,,,,,,,,,,,,17.44,,,percent of total billed charges,,,,,,,,,16.13,,,percent of total billed charges,,,16.13,,,percent of total billed charges,,,,,,,,,43.59,,,percent of total billed charges,,,43.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.49,,,percent of total billed charges,,,43.59,,,percent of total billed charges,,,,,,,,,,,,,,,43.59,,,percent of total billed charges,,,43.59,,,percent of total billed charges,,,,,,,,,40.55,,,percent of total billed charges,,,,,,,,,,,,,,,40.55,,,percent of total billed charges,,,40.55,,,percent of total billed charges,,,40.55,,,percent of total billed charges,,,32.69,,,percent of total billed charges,,,43.59,,,percent of total billed charges,,,43.59,,,percent of total billed charges,,,43.59,,,percent of total billed charges,,,,,,,,,30.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,25.68,,,percent of total billed charges,,
METHYLPHENIDATE 18 MG TABCR,2500013666,CDM,637,RC,3172295201,NDC,999,EAPG,,,,outpatient,facility,18,UN,43.59,43.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLPREDNISOLONE 4MG TAB,2500013670,CDM,637,RC,J7509,HCPCS,5974600106,NDC,,,,inpatient,facility,4,UN,5.44,5.44,0.44,5.44,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,,,,,,,5.44,,,percent of total billed charges,,,2.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.21,,,percent of total billed charges,,
METHYLPREDNISOLONE 4MG TAB,2500013670,CDM,637,RC,J7509,HCPCS,5974600106,NDC,,,,outpatient,facility,4,UN,5.44,5.44,0.25,548.68,,3.86,,,percent of total billed charges,,,1.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.44,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.99,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.44,,,fee schedule,,,5.44,,,percent of total billed charges,,,,,,,,,5.44,,,percent of total billed charges,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,3.21,,,percent of total billed charges,,,548.68,,,per diem,,,5.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.44,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.67,,,percent of total billed charges,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,5.44,,,percent of total billed charges,,,5.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.44,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.25,,,fee schedule,,,5.44,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,5.44,,,percent of total billed charges,,,,,,,,,3.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.21,,,percent of total billed charges,,
METHYLPREDNISOLONE 4MG TAB,2500013670,CDM,637,RC,J7509,HCPCS,5974600106,NDC,496,EAPG,,outpatient,facility,4,UN,5.44,5.44,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOCLOPRAMIDE 10 MG TAB,2500013700,CDM,637,RC,J8597,HCPCS,5107988820,NDC,,,,inpatient,facility,10,UN,3.17,3.17,0.25,3.17,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,2.69,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,
METOCLOPRAMIDE 10 MG TAB,2500013700,CDM,637,RC,J8597,HCPCS,5107988820,NDC,,,,outpatient,facility,10,UN,3.17,3.17,0.25,548.68,,2.25,,,percent of total billed charges,,,0.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.16,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.17,,,fee schedule,,,3.17,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,1.87,,,percent of total billed charges,,,548.68,,,per diem,,,3.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.17,,,percent of total billed charges,,,2.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3.17,,,percent of total billed charges,,,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.25,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.38,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,2.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.87,,,percent of total billed charges,,
METOCLOPRAMIDE 10 MG TAB,2500013700,CDM,637,RC,J8597,HCPCS,5107988820,NDC,999,EAPG,,outpatient,facility,10,UN,3.17,3.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOCLOPRAMIDE 5 MG/5 ML 10 ML,2500013706,CDM,637,RC,J8597,HCPCS,121157610,NDC,,,,inpatient,facility,10,UN,16.04,16.04,1.28,16.04,,,,,,,,,,,,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.04,,,percent of total billed charges,,,,,,,,,16.04,,,percent of total billed charges,,,8.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.62,,,percent of total billed charges,,,,,,,,,,,,,,,16.04,,,percent of total billed charges,,,13.63,,,percent of total billed charges,,,,,,,,,,,,,,,16.04,,,percent of total billed charges,,,8.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.45,,,percent of total billed charges,,
METOCLOPRAMIDE 5 MG/5 ML 10 ML,2500013706,CDM,637,RC,J8597,HCPCS,121157610,NDC,,,,outpatient,facility,10,UN,16.04,16.04,1.28,548.68,,11.37,,,percent of total billed charges,,,3.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,16.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,16.04,,,fee schedule,,,16.04,,,percent of total billed charges,,,,,,,,,16.04,,,percent of total billed charges,,,9.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,9.46,,,percent of total billed charges,,,548.68,,,per diem,,,16.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,16.04,,,percent of total billed charges,,,13.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.52,,,percent of total billed charges,,,16.04,,,percent of total billed charges,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,12.98,,,percent of total billed charges,,,,,,,,,,,,,,,6.42,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,16.04,,,percent of total billed charges,,,16.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.28,,,percent of total billed charges,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,16.04,,,percent of total billed charges,,,16.04,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,12.03,,,percent of total billed charges,,,16.04,,,percent of total billed charges,,,16.04,,,percent of total billed charges,,,16.04,,,percent of total billed charges,,,,,,,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.45,,,percent of total billed charges,,
METOCLOPRAMIDE 5 MG/5 ML 10 ML,2500013706,CDM,637,RC,J8597,HCPCS,121157610,NDC,999,EAPG,,outpatient,facility,10,UN,16.04,16.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOLAZONE 2.5 MG TAB,2500013722,CDM,637,RC,185505001,NDC,,,,,,inpatient,facility,2.5,UN,6.83,6.83,0.55,6.83,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,,,,,,,,6.83,,,percent of total billed charges,,,3.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.1,,,percent of total billed charges,,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.02,,,percent of total billed charges,,
METOLAZONE 2.5 MG TAB,2500013722,CDM,637,RC,185505001,NDC,,,,,,outpatient,facility,2.5,UN,6.83,6.83,0.55,548.68,,4.84,,,percent of total billed charges,,,1.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.83,,,percent of total billed charges,,,4.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.5,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.83,,,fee schedule,,,6.83,,,percent of total billed charges,,,,,,,,,6.83,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.87,,,percent of total billed charges,,,,,,,,,,,,,,,3.69,,,percent of total billed charges,,,3.55,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,4.03,,,percent of total billed charges,,,548.68,,,per diem,,,6.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.83,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.61,,,percent of total billed charges,,,5.53,,,percent of total billed charges,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,,,,,,,2.53,,,percent of total billed charges,,,2.53,,,percent of total billed charges,,,,,,,,,6.83,,,percent of total billed charges,,,6.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.55,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,6.83,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,,,,,,,6.35,,,percent of total billed charges,,,,,,,,,,,,,,,6.35,,,percent of total billed charges,,,6.35,,,percent of total billed charges,,,6.35,,,percent of total billed charges,,,5.12,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,6.83,,,percent of total billed charges,,,,,,,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.02,,,percent of total billed charges,,
METOLAZONE 2.5 MG TAB,2500013722,CDM,637,RC,185505001,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,6.83,6.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOPROLOL 5 MG/ML,2500013730,CDM,637,RC,J3490,HCPCS,143966010,NDC,,,,inpatient,facility,1,UN,1.78,1.78,0.14,1.78,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,1.78,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,
METOPROLOL 5 MG/ML,2500013730,CDM,637,RC,J3490,HCPCS,143966010,NDC,,,,outpatient,facility,1,UN,1.78,1.78,0.14,548.68,,1.26,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,1.78,,,fee schedule,,,1.78,,,percent of total billed charges,,,,,,,,,1.78,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,1.05,,,percent of total billed charges,,,548.68,,,per diem,,,1.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.78,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1.78,,,percent of total billed charges,,,1.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.14,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.33,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.05,,,percent of total billed charges,,
METOPROLOL 5 MG/ML,2500013730,CDM,637,RC,J3490,HCPCS,143966010,NDC,435,EAPG,,outpatient,facility,1,UN,1.78,1.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOPROLOL SUCC 50 MG TABCR,2500013736,CDM,637,RC,4596367696,NDC,,,,,,inpatient,facility,50,UN,3.46,3.46,0.28,3.46,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,,,,,,,3.46,,,percent of total billed charges,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,
METOPROLOL SUCC 50 MG TABCR,2500013736,CDM,637,RC,4596367696,NDC,,,,,,outpatient,facility,50,UN,3.46,3.46,0.28,548.68,,2.45,,,percent of total billed charges,,,0.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.46,,,percent of total billed charges,,,2.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.27,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.46,,,fee schedule,,,3.46,,,percent of total billed charges,,,,,,,,,3.46,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,548.68,,,per diem,,,3.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.46,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,1.28,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,3.46,,,percent of total billed charges,,,3.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,,,,,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,3.22,,,percent of total billed charges,,,3.22,,,percent of total billed charges,,,2.59,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,,,,,,,2.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.04,,,percent of total billed charges,,
METOPROLOL SUCC 50 MG TABCR,2500013736,CDM,637,RC,4596367696,NDC,999,EAPG,,,,outpatient,facility,50,UN,3.46,3.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOPROLOL TART 5 MG/5 ML AMP,2500013740,CDM,250,RC,J3490,HCPCS,7261174010,NDC,,,,inpatient,facility,5,UN,3.89,3.89,0.31,3.89,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,,,,,,,3.89,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.29,,,percent of total billed charges,,
METOPROLOL TART 5 MG/5 ML AMP,2500013740,CDM,250,RC,J3490,HCPCS,7261174010,NDC,,,,outpatient,facility,5,UN,3.89,3.89,0.31,548.68,,2.76,,,percent of total billed charges,,,0.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.89,,,percent of total billed charges,,,2.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.42,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,3.89,,,fee schedule,,,3.89,,,percent of total billed charges,,,,,,,,,3.89,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,2.3,,,percent of total billed charges,,,548.68,,,per diem,,,3.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.89,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.07,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,3.15,,,percent of total billed charges,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3.89,,,percent of total billed charges,,,3.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.31,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.92,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.29,,,percent of total billed charges,,
METOPROLOL TART 5 MG/5 ML AMP,2500013740,CDM,250,RC,J3490,HCPCS,7261174010,NDC,435,EAPG,,outpatient,facility,5,UN,3.89,3.89,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOPROLOL TART 50 MG TAB,2500013745,CDM,637,RC,5107980120,NDC,,,,,,inpatient,facility,50,UN,1.88,1.88,0.15,1.88,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,
METOPROLOL TART 50 MG TAB,2500013745,CDM,637,RC,5107980120,NDC,,,,,,outpatient,facility,50,UN,1.88,1.88,0.15,548.68,,1.33,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.88,,,percent of total billed charges,,,1.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.69,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.88,,,fee schedule,,,1.88,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,1.11,,,percent of total billed charges,,,548.68,,,per diem,,,1.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.88,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,0.7,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.11,,,percent of total billed charges,,
METOPROLOL TART 50 MG TAB,2500013745,CDM,637,RC,5107980120,NDC,999,EAPG,,,,outpatient,facility,50,UN,1.88,1.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOPROLOL TART 25 MG TAB,2500013748,CDM,637,RC,5107925520,NDC,,,,,,inpatient,facility,25,UN,0.79,0.79,0.06,0.79,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,
METOPROLOL TART 25 MG TAB,2500013748,CDM,637,RC,5107925520,NDC,,,,,,outpatient,facility,25,UN,0.79,0.79,0.06,548.68,,0.56,,,percent of total billed charges,,,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.79,,,percent of total billed charges,,,0.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.79,,,fee schedule,,,0.79,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,0.47,,,percent of total billed charges,,,548.68,,,per diem,,,0.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.79,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.47,,,percent of total billed charges,,
METOPROLOL TART 25 MG TAB,2500013748,CDM,637,RC,5107925520,NDC,999,EAPG,,,,outpatient,facility,25,UN,0.79,0.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METRONIDAZOLE 0.75   70GM VAG,2500013760,CDM,637,RC,245086070,NDC,,,,,,inpatient,facility,70,UN,538.03,538.03,43.04,538.03,,,,,,,,,,,,,,538.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,538.03,,,percent of total billed charges,,,,,,,,,538.03,,,percent of total billed charges,,,274.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,322.82,,,percent of total billed charges,,,,,,,,,,,,,,,538.03,,,percent of total billed charges,,,457.33,,,percent of total billed charges,,,,,,,,,,,,,,,538.03,,,percent of total billed charges,,,285.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,538.03,,,percent of total billed charges,,,,,,,,,,,,,,,43.04,,,percent of total billed charges,,,538.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,538.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,317.01,,,percent of total billed charges,,
METRONIDAZOLE 0.75   70GM VAG,2500013760,CDM,637,RC,245086070,NDC,,,,,,outpatient,facility,70,UN,538.03,538.03,43.04,548.68,,381.52,,,percent of total billed charges,,,131.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,538.03,,,percent of total billed charges,,,337.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,378.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,378.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,538.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,196.92,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,538.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,538.03,,,fee schedule,,,538.03,,,percent of total billed charges,,,,,,,,,538.03,,,percent of total billed charges,,,329.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.35,,,percent of total billed charges,,,,,,,,,,,,,,,290.54,,,percent of total billed charges,,,279.78,,,percent of total billed charges,,,295.92,,,percent of total billed charges,,,,,,,,,317.44,,,percent of total billed charges,,,548.68,,,per diem,,,538.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,538.03,,,percent of total billed charges,,,457.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,285.75,,,percent of total billed charges,,,538.03,,,percent of total billed charges,,,538.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,362.96,,,percent of total billed charges,,,435.37,,,percent of total billed charges,,,,,,,,,,,,,,,215.21,,,percent of total billed charges,,,,,,,,,199.07,,,percent of total billed charges,,,199.07,,,percent of total billed charges,,,,,,,,,538.03,,,percent of total billed charges,,,538.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,538.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.04,,,percent of total billed charges,,,538.03,,,percent of total billed charges,,,,,,,,,,,,,,,538.03,,,percent of total billed charges,,,538.03,,,percent of total billed charges,,,,,,,,,500.48,,,percent of total billed charges,,,,,,,,,,,,,,,500.48,,,percent of total billed charges,,,500.48,,,percent of total billed charges,,,500.48,,,percent of total billed charges,,,403.52,,,percent of total billed charges,,,538.03,,,percent of total billed charges,,,538.03,,,percent of total billed charges,,,538.03,,,percent of total billed charges,,,,,,,,,377.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,269.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,317.01,,,percent of total billed charges,,
METRONIDAZOLE 0.75   70GM VAG,2500013760,CDM,637,RC,245086070,NDC,999,EAPG,,,,outpatient,facility,70,UN,538.03,538.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METRONIDAZOLE 0.75  45 GM,2500013761,CDM,637,RC,168032346,NDC,,,,,,inpatient,facility,45,UN,235.46,235.46,18.84,235.46,,,,,,,,,,,,,,235.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.46,,,percent of total billed charges,,,,,,,,,235.46,,,percent of total billed charges,,,120.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.28,,,percent of total billed charges,,,,,,,,,,,,,,,235.46,,,percent of total billed charges,,,200.14,,,percent of total billed charges,,,,,,,,,,,,,,,235.46,,,percent of total billed charges,,,125.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,235.46,,,percent of total billed charges,,,,,,,,,,,,,,,18.84,,,percent of total billed charges,,,235.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,235.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.73,,,percent of total billed charges,,
METRONIDAZOLE 0.75  45 GM,2500013761,CDM,637,RC,168032346,NDC,,,,,,outpatient,facility,45,UN,235.46,235.46,18.84,548.68,,166.96,,,percent of total billed charges,,,57.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,235.46,,,percent of total billed charges,,,147.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,165.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,165.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,235.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,86.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,235.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,235.46,,,fee schedule,,,235.46,,,percent of total billed charges,,,,,,,,,235.46,,,percent of total billed charges,,,144.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.77,,,percent of total billed charges,,,,,,,,,,,,,,,127.15,,,percent of total billed charges,,,122.44,,,percent of total billed charges,,,129.5,,,percent of total billed charges,,,,,,,,,138.92,,,percent of total billed charges,,,548.68,,,per diem,,,235.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,235.46,,,percent of total billed charges,,,200.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,125.05,,,percent of total billed charges,,,235.46,,,percent of total billed charges,,,235.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.84,,,percent of total billed charges,,,190.53,,,percent of total billed charges,,,,,,,,,,,,,,,94.18,,,percent of total billed charges,,,,,,,,,87.12,,,percent of total billed charges,,,87.12,,,percent of total billed charges,,,,,,,,,235.46,,,percent of total billed charges,,,235.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,235.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.84,,,percent of total billed charges,,,235.46,,,percent of total billed charges,,,,,,,,,,,,,,,235.46,,,percent of total billed charges,,,235.46,,,percent of total billed charges,,,,,,,,,219.02,,,percent of total billed charges,,,,,,,,,,,,,,,219.02,,,percent of total billed charges,,,219.02,,,percent of total billed charges,,,219.02,,,percent of total billed charges,,,176.59,,,percent of total billed charges,,,235.46,,,percent of total billed charges,,,235.46,,,percent of total billed charges,,,235.46,,,percent of total billed charges,,,,,,,,,165.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,138.73,,,percent of total billed charges,,
METRONIDAZOLE 0.75  45 GM,2500013761,CDM,637,RC,168032346,NDC,999,EAPG,,,,outpatient,facility,45,UN,235.46,235.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METRONIDAZOLE 250 MG 50 ML IV,2500013763,CDM,250,RC,J3490,HCPCS,409781124,NDC,,,,inpatient,facility,50,UN,3.17,3.17,0.25,3.17,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,2.69,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,
METRONIDAZOLE 250 MG 50 ML IV,2500013763,CDM,250,RC,J3490,HCPCS,409781124,NDC,,,,outpatient,facility,50,UN,3.17,3.17,0.25,548.68,,2.25,,,percent of total billed charges,,,0.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.17,,,percent of total billed charges,,,1.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.16,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,3.17,,,fee schedule,,,3.17,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,1.87,,,percent of total billed charges,,,548.68,,,per diem,,,3.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.17,,,percent of total billed charges,,,2.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3.17,,,percent of total billed charges,,,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.25,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.38,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,2.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.87,,,percent of total billed charges,,
METRONIDAZOLE 250 MG 50 ML IV,2500013763,CDM,250,RC,J3490,HCPCS,409781124,NDC,435,EAPG,,outpatient,facility,50,UN,3.17,3.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METRONIDAZOLE 500 MG TAB,2500013766,CDM,637,RC,2315565201,NDC,,,,,,inpatient,facility,500,UN,2.41,2.41,0.19,2.41,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,2.41,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,
METRONIDAZOLE 500 MG TAB,2500013766,CDM,637,RC,2315565201,NDC,,,,,,outpatient,facility,500,UN,2.41,2.41,0.19,548.68,,1.71,,,percent of total billed charges,,,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.41,,,percent of total billed charges,,,1.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.88,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.41,,,fee schedule,,,2.41,,,percent of total billed charges,,,,,,,,,2.41,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,548.68,,,per diem,,,2.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.41,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,,,,,,,0.89,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,2.41,,,percent of total billed charges,,,2.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.19,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.42,,,percent of total billed charges,,
METRONIDAZOLE 500 MG TAB,2500013766,CDM,637,RC,2315565201,NDC,999,EAPG,,,,outpatient,facility,500,UN,2.41,2.41,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METRONIDAZOLE 500 MG/100 ML,2500013769,CDM,250,RC,J3490,HCPCS,409781124,NDC,,,,inpatient,facility,100,UN,6.34,6.34,0.51,6.34,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,6.34,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,5.39,,,percent of total billed charges,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.74,,,percent of total billed charges,,
METRONIDAZOLE 500 MG/100 ML,2500013769,CDM,250,RC,J3490,HCPCS,409781124,NDC,,,,outpatient,facility,100,UN,6.34,6.34,0.51,548.68,,4.5,,,percent of total billed charges,,,1.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.34,,,percent of total billed charges,,,3.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.32,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,6.34,,,fee schedule,,,6.34,,,percent of total billed charges,,,,,,,,,6.34,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.52,,,percent of total billed charges,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,3.74,,,percent of total billed charges,,,548.68,,,per diem,,,6.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.34,,,percent of total billed charges,,,5.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,5.13,,,percent of total billed charges,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6.34,,,percent of total billed charges,,,6.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.51,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,4.75,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,,,,,,,4.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.74,,,percent of total billed charges,,
METRONIDAZOLE 500 MG/100 ML,2500013769,CDM,250,RC,J3490,HCPCS,409781124,NDC,435,EAPG,,outpatient,facility,100,UN,6.34,6.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEXILETINE HCL 150 MG CAP,2500013770,CDM,637,RC,93873901,NDC,,,,,,inpatient,facility,150,UN,8.38,8.38,0.67,8.38,,,,,,,,,,,,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.38,,,percent of total billed charges,,,,,,,,,8.38,,,percent of total billed charges,,,4.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,8.38,,,percent of total billed charges,,,7.12,,,percent of total billed charges,,,,,,,,,,,,,,,8.38,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,
MEXILETINE HCL 150 MG CAP,2500013770,CDM,637,RC,93873901,NDC,,,,,,outpatient,facility,150,UN,8.38,8.38,0.67,548.68,,5.94,,,percent of total billed charges,,,2.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.38,,,percent of total billed charges,,,5.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.07,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.38,,,fee schedule,,,8.38,,,percent of total billed charges,,,,,,,,,8.38,,,percent of total billed charges,,,5.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,4.36,,,percent of total billed charges,,,4.61,,,percent of total billed charges,,,,,,,,,4.94,,,percent of total billed charges,,,548.68,,,per diem,,,8.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.38,,,percent of total billed charges,,,7.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.65,,,percent of total billed charges,,,6.78,,,percent of total billed charges,,,,,,,,,,,,,,,3.35,,,percent of total billed charges,,,,,,,,,3.1,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,8.38,,,percent of total billed charges,,,8.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.67,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,8.38,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,,,,,,,7.8,,,percent of total billed charges,,,,,,,,,,,,,,,7.8,,,percent of total billed charges,,,7.8,,,percent of total billed charges,,,7.8,,,percent of total billed charges,,,6.29,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,,,,,,,5.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.94,,,percent of total billed charges,,
MEXILETINE HCL 150 MG CAP,2500013770,CDM,637,RC,93873901,NDC,999,EAPG,,,,outpatient,facility,150,UN,8.38,8.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEXILETINE HCL 200 MG CAP,2500013772,CDM,637,RC,93874001,NDC,,,,,,inpatient,facility,200,UN,10,10,0.8,10,,,,,,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,10,,,percent of total billed charges,,,5.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,8.5,,,percent of total billed charges,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,5.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.89,,,percent of total billed charges,,
MEXILETINE HCL 200 MG CAP,2500013772,CDM,637,RC,93874001,NDC,,,,,,outpatient,facility,200,UN,10,10,0.8,548.68,,7.09,,,percent of total billed charges,,,2.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10,,,percent of total billed charges,,,6.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.66,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10,,,fee schedule,,,10,,,percent of total billed charges,,,,,,,,,10,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,5.4,,,percent of total billed charges,,,5.2,,,percent of total billed charges,,,5.5,,,percent of total billed charges,,,,,,,,,5.9,,,percent of total billed charges,,,548.68,,,per diem,,,10,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10,,,percent of total billed charges,,,8.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,10,,,percent of total billed charges,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.75,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,4,,,percent of total billed charges,,,,,,,,,3.7,,,percent of total billed charges,,,3.7,,,percent of total billed charges,,,,,,,,,10,,,percent of total billed charges,,,10,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.8,,,percent of total billed charges,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,10,,,percent of total billed charges,,,,,,,,,9.3,,,percent of total billed charges,,,,,,,,,,,,,,,9.3,,,percent of total billed charges,,,9.3,,,percent of total billed charges,,,9.3,,,percent of total billed charges,,,7.5,,,percent of total billed charges,,,10,,,percent of total billed charges,,,10,,,percent of total billed charges,,,10,,,percent of total billed charges,,,,,,,,,7.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.89,,,percent of total billed charges,,
MEXILETINE HCL 200 MG CAP,2500013772,CDM,637,RC,93874001,NDC,999,EAPG,,,,outpatient,facility,200,UN,10,10,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MICONAZOLE  2  VAG CR 47.7 GM,2500013803,CDM,637,RC,5167220356,NDC,,,,,,inpatient,facility,45,UN,17.18,17.18,1.37,17.18,,,,,,,,,,,,,,17.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.18,,,percent of total billed charges,,,,,,,,,17.18,,,percent of total billed charges,,,8.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.31,,,percent of total billed charges,,,,,,,,,,,,,,,17.18,,,percent of total billed charges,,,14.6,,,percent of total billed charges,,,,,,,,,,,,,,,17.18,,,percent of total billed charges,,,9.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,17.18,,,percent of total billed charges,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,17.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.12,,,percent of total billed charges,,
MICONAZOLE  2  VAG CR 47.7 GM,2500013803,CDM,637,RC,5167220356,NDC,,,,,,outpatient,facility,45,UN,17.18,17.18,1.37,548.68,,12.18,,,percent of total billed charges,,,4.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,17.18,,,percent of total billed charges,,,10.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,12.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,12.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,17.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,17.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,17.18,,,fee schedule,,,17.18,,,percent of total billed charges,,,,,,,,,17.18,,,percent of total billed charges,,,10.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.24,,,percent of total billed charges,,,,,,,,,,,,,,,9.28,,,percent of total billed charges,,,8.93,,,percent of total billed charges,,,9.45,,,percent of total billed charges,,,,,,,,,10.14,,,percent of total billed charges,,,548.68,,,per diem,,,17.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,17.18,,,percent of total billed charges,,,14.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.12,,,percent of total billed charges,,,17.18,,,percent of total billed charges,,,17.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.59,,,percent of total billed charges,,,13.9,,,percent of total billed charges,,,,,,,,,,,,,,,6.87,,,percent of total billed charges,,,,,,,,,6.36,,,percent of total billed charges,,,6.36,,,percent of total billed charges,,,,,,,,,17.18,,,percent of total billed charges,,,17.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.37,,,percent of total billed charges,,,17.18,,,percent of total billed charges,,,,,,,,,,,,,,,17.18,,,percent of total billed charges,,,17.18,,,percent of total billed charges,,,,,,,,,15.98,,,percent of total billed charges,,,,,,,,,,,,,,,15.98,,,percent of total billed charges,,,15.98,,,percent of total billed charges,,,15.98,,,percent of total billed charges,,,12.88,,,percent of total billed charges,,,17.18,,,percent of total billed charges,,,17.18,,,percent of total billed charges,,,17.18,,,percent of total billed charges,,,,,,,,,12.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.12,,,percent of total billed charges,,
MICONAZOLE  2  VAG CR 47.7 GM,2500013803,CDM,637,RC,5167220356,NDC,999,EAPG,,,,outpatient,facility,45,UN,17.18,17.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MIDAZOLAM/NS 100MG/100ML IV,2500013824,CDM,636,RC,J2250,HCPCS,4285240110,NDC,,,,inpatient,facility,100,UN,83.09,83.09,6.65,83.09,,,,,,,,,,,,,,83.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.09,,,percent of total billed charges,,,,,,,,,83.09,,,percent of total billed charges,,,42.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.85,,,percent of total billed charges,,,,,,,,,,,,,,,83.09,,,percent of total billed charges,,,70.63,,,percent of total billed charges,,,,,,,,,,,,,,,83.09,,,percent of total billed charges,,,44.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,83.09,,,percent of total billed charges,,,,,,,,,,,,,,,6.65,,,percent of total billed charges,,,83.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,83.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.96,,,percent of total billed charges,,
MIDAZOLAM/NS 100MG/100ML IV,2500013824,CDM,636,RC,J2250,HCPCS,4285240110,NDC,,,,outpatient,facility,100,UN,83.09,83.09,0.08,548.68,,58.92,,,percent of total billed charges,,,20.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,83.09,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,83.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,30.41,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.08,,,fee schedule,,,83.09,,,fee schedule,,,83.09,,,percent of total billed charges,,,,,,,,,83.09,,,percent of total billed charges,,,50.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,49.02,,,percent of total billed charges,,,548.68,,,per diem,,,83.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,83.09,,,percent of total billed charges,,,70.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,44.13,,,percent of total billed charges,,,83.09,,,percent of total billed charges,,,83.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.05,,,percent of total billed charges,,,67.24,,,percent of total billed charges,,,,,,,,,,,,,,,33.24,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,83.09,,,percent of total billed charges,,,83.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,83.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.65,,,percent of total billed charges,,,83.09,,,percent of total billed charges,,,,,,,,,,,,,,,83.09,,,percent of total billed charges,,,83.09,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.14,,,fee schedule,,,83.09,,,percent of total billed charges,,,83.09,,,percent of total billed charges,,,83.09,,,percent of total billed charges,,,,,,,,,58.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,48.96,,,percent of total billed charges,,
MIDAZOLAM/NS 100MG/100ML IV,2500013824,CDM,636,RC,J2250,HCPCS,4285240110,NDC,496,EAPG,,outpatient,facility,100,UN,83.09,83.09,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MIDODRINE 2.5 MG TAB,2500013830,CDM,637,RC,245021111,NDC,,,,,,inpatient,facility,2.5,UN,5.57,5.57,0.45,5.57,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,,,,,,,5.57,,,percent of total billed charges,,,2.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.34,,,percent of total billed charges,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,4.73,,,percent of total billed charges,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,2.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,5.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.28,,,percent of total billed charges,,
MIDODRINE 2.5 MG TAB,2500013830,CDM,637,RC,245021111,NDC,,,,,,outpatient,facility,2.5,UN,5.57,5.57,0.45,548.68,,3.95,,,percent of total billed charges,,,1.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.57,,,percent of total billed charges,,,3.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.04,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.57,,,fee schedule,,,5.57,,,percent of total billed charges,,,,,,,,,5.57,,,percent of total billed charges,,,3.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.97,,,percent of total billed charges,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,3.06,,,percent of total billed charges,,,,,,,,,3.29,,,percent of total billed charges,,,548.68,,,per diem,,,5.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.57,,,percent of total billed charges,,,4.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.96,,,percent of total billed charges,,,5.57,,,percent of total billed charges,,,5.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,4.51,,,percent of total billed charges,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,,,,,,,2.06,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,,,,,,,5.57,,,percent of total billed charges,,,5.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.45,,,percent of total billed charges,,,5.57,,,percent of total billed charges,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,5.57,,,percent of total billed charges,,,,,,,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,5.18,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,4.18,,,percent of total billed charges,,,5.57,,,percent of total billed charges,,,5.57,,,percent of total billed charges,,,5.57,,,percent of total billed charges,,,,,,,,,3.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.79,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.28,,,percent of total billed charges,,
MIDODRINE 2.5 MG TAB,2500013830,CDM,637,RC,245021111,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,5.57,5.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MIDODRINE 5 MG TAB,2500013832,CDM,637,RC,904681861,NDC,,,,,,inpatient,facility,5,UN,2.87,2.87,0.23,2.87,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,2.87,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,
MIDODRINE 5 MG TAB,2500013832,CDM,637,RC,904681861,NDC,,,,,,outpatient,facility,5,UN,2.87,2.87,0.23,548.68,,2.04,,,percent of total billed charges,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.87,,,percent of total billed charges,,,1.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.87,,,fee schedule,,,2.87,,,percent of total billed charges,,,,,,,,,2.87,,,percent of total billed charges,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,1.69,,,percent of total billed charges,,,548.68,,,per diem,,,2.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.87,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,2.32,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,1.06,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,2.87,,,percent of total billed charges,,,2.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.69,,,percent of total billed charges,,
MIDODRINE 5 MG TAB,2500013832,CDM,637,RC,904681861,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.87,2.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MINERAL OIL ENEMA 133 ML,2500013875,CDM,637,RC,7000001091,NDC,,,,,,inpatient,facility,133,UN,4.19,4.19,0.34,4.19,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,4.19,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,
MINERAL OIL ENEMA 133 ML,2500013875,CDM,637,RC,7000001091,NDC,,,,,,outpatient,facility,133,UN,4.19,4.19,0.34,548.68,,2.97,,,percent of total billed charges,,,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.19,,,percent of total billed charges,,,2.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.53,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.19,,,fee schedule,,,4.19,,,percent of total billed charges,,,,,,,,,4.19,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,,,,,,,2.47,,,percent of total billed charges,,,548.68,,,per diem,,,4.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.19,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.83,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,4.19,,,percent of total billed charges,,,4.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.34,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,3.9,,,percent of total billed charges,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,3.9,,,percent of total billed charges,,,3.9,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.47,,,percent of total billed charges,,
MINERAL OIL ENEMA 133 ML,2500013875,CDM,637,RC,7000001091,NDC,999,EAPG,,,,outpatient,facility,133,UN,4.19,4.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MINERAL OIL LIGHT 10 ML UD,2500013883,CDM,637,RC,6332325410,NDC,,,,,,inpatient,facility,10,UN,29.97,29.97,2.4,29.97,,,,,,,,,,,,,,29.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.97,,,percent of total billed charges,,,,,,,,,29.97,,,percent of total billed charges,,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.98,,,percent of total billed charges,,,,,,,,,,,,,,,29.97,,,percent of total billed charges,,,25.47,,,percent of total billed charges,,,,,,,,,,,,,,,29.97,,,percent of total billed charges,,,15.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,29.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,
MINERAL OIL LIGHT 10 ML UD,2500013883,CDM,637,RC,6332325410,NDC,,,,,,outpatient,facility,10,UN,29.97,29.97,2.4,548.68,,21.25,,,percent of total billed charges,,,7.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,29.97,,,percent of total billed charges,,,18.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,21.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,21.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,29.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.97,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,29.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,29.97,,,fee schedule,,,29.97,,,percent of total billed charges,,,,,,,,,29.97,,,percent of total billed charges,,,18.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,16.18,,,percent of total billed charges,,,15.58,,,percent of total billed charges,,,16.48,,,percent of total billed charges,,,,,,,,,17.68,,,percent of total billed charges,,,548.68,,,per diem,,,29.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,29.97,,,percent of total billed charges,,,25.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.92,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.22,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,,,,,,,,,,,,,11.99,,,percent of total billed charges,,,,,,,,,11.09,,,percent of total billed charges,,,11.09,,,percent of total billed charges,,,,,,,,,29.97,,,percent of total billed charges,,,29.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.4,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,,,,,,,,,,,,,29.97,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,,,,,,,27.88,,,percent of total billed charges,,,,,,,,,,,,,,,27.88,,,percent of total billed charges,,,27.88,,,percent of total billed charges,,,27.88,,,percent of total billed charges,,,22.48,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,,,,,,,21.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.66,,,percent of total billed charges,,
MINERAL OIL LIGHT 10 ML UD,2500013883,CDM,637,RC,6332325410,NDC,999,EAPG,,,,outpatient,facility,10,UN,29.97,29.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MINOCYCLINE HCL 50 MG CAP,2500013892,CDM,637,RC,6838231601,NDC,,,,,,inpatient,facility,50,UN,5.61,5.61,0.45,5.61,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,5.61,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,
MINOCYCLINE HCL 50 MG CAP,2500013892,CDM,637,RC,6838231601,NDC,,,,,,outpatient,facility,50,UN,5.61,5.61,0.45,548.68,,3.98,,,percent of total billed charges,,,1.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.61,,,percent of total billed charges,,,3.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.61,,,fee schedule,,,5.61,,,percent of total billed charges,,,,,,,,,5.61,,,percent of total billed charges,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4,,,percent of total billed charges,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,,2.92,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,,,,,,,3.31,,,percent of total billed charges,,,548.68,,,per diem,,,5.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.61,,,percent of total billed charges,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.78,,,percent of total billed charges,,,4.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,5.61,,,percent of total billed charges,,,5.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.45,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,5.22,,,percent of total billed charges,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.31,,,percent of total billed charges,,
MINOCYCLINE HCL 50 MG CAP,2500013892,CDM,637,RC,6838231601,NDC,999,EAPG,,,,outpatient,facility,50,UN,5.61,5.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MINOXIDIL 2.5 MG TAB,2500013902,CDM,637,RC,6808420401,NDC,,,,,,inpatient,facility,2.5,UN,5.61,5.61,0.45,5.61,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,5.61,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,
MINOXIDIL 2.5 MG TAB,2500013902,CDM,637,RC,6808420401,NDC,,,,,,outpatient,facility,2.5,UN,5.61,5.61,0.45,548.68,,3.98,,,percent of total billed charges,,,1.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.61,,,percent of total billed charges,,,3.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.61,,,fee schedule,,,5.61,,,percent of total billed charges,,,,,,,,,5.61,,,percent of total billed charges,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4,,,percent of total billed charges,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,,2.92,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,,,,,,,3.31,,,percent of total billed charges,,,548.68,,,per diem,,,5.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.61,,,percent of total billed charges,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.78,,,percent of total billed charges,,,4.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,5.61,,,percent of total billed charges,,,5.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.45,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,5.22,,,percent of total billed charges,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.31,,,percent of total billed charges,,
MINOXIDIL 2.5 MG TAB,2500013902,CDM,637,RC,6808420401,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,5.61,5.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MIRTAZAPINE 15 MG TAB,2500013910,CDM,637,RC,904651961,NDC,,,,,,inpatient,facility,15,UN,0.52,0.52,0.04,0.52,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,0.52,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,
MIRTAZAPINE 15 MG TAB,2500013910,CDM,637,RC,904651961,NDC,,,,,,outpatient,facility,15,UN,0.52,0.52,0.04,548.68,,0.37,,,percent of total billed charges,,,0.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.52,,,percent of total billed charges,,,0.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.19,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.52,,,fee schedule,,,0.52,,,percent of total billed charges,,,,,,,,,0.52,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.31,,,percent of total billed charges,,,548.68,,,per diem,,,0.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.52,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,0.19,,,percent of total billed charges,,,0.19,,,percent of total billed charges,,,,,,,,,0.52,,,percent of total billed charges,,,0.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.31,,,percent of total billed charges,,
MIRTAZAPINE 15 MG TAB,2500013910,CDM,637,RC,904651961,NDC,999,EAPG,,,,outpatient,facility,15,UN,0.52,0.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MISOPROSTOL 100 MCG TAB,2500013930,CDM,637,RC,5976250071,NDC,,,,,,inpatient,facility,100,UN,2.17,2.17,0.17,2.17,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,2.17,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,
MISOPROSTOL 100 MCG TAB,2500013930,CDM,637,RC,5976250071,NDC,,,,,,outpatient,facility,100,UN,2.17,2.17,0.17,548.68,,1.54,,,percent of total billed charges,,,0.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.17,,,percent of total billed charges,,,1.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.79,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.17,,,fee schedule,,,2.17,,,percent of total billed charges,,,,,,,,,2.17,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,1.28,,,percent of total billed charges,,,548.68,,,per diem,,,2.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.17,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.46,,,percent of total billed charges,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,0.8,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,2.17,,,percent of total billed charges,,,2.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.28,,,percent of total billed charges,,
MISOPROSTOL 100 MCG TAB,2500013930,CDM,637,RC,5976250071,NDC,999,EAPG,,,,outpatient,facility,100,UN,2.17,2.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MONTELUKAST 4 MG CHEW TAB,2500014008,CDM,637,RC,3334211010,NDC,,,,,,inpatient,facility,4,UN,16.6,16.6,1.33,16.6,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,,,,,,,16.6,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.96,,,percent of total billed charges,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,14.11,,,percent of total billed charges,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,8.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,
MONTELUKAST 4 MG CHEW TAB,2500014008,CDM,637,RC,3334211010,NDC,,,,,,outpatient,facility,4,UN,16.6,16.6,1.33,548.68,,11.77,,,percent of total billed charges,,,4.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,16.6,,,percent of total billed charges,,,10.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,11.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,11.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,16.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,16.6,,,fee schedule,,,16.6,,,percent of total billed charges,,,,,,,,,16.6,,,percent of total billed charges,,,10.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.83,,,percent of total billed charges,,,,,,,,,,,,,,,8.96,,,percent of total billed charges,,,8.63,,,percent of total billed charges,,,9.13,,,percent of total billed charges,,,,,,,,,9.79,,,percent of total billed charges,,,548.68,,,per diem,,,16.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,16.6,,,percent of total billed charges,,,14.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.82,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.2,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,6.64,,,percent of total billed charges,,,,,,,,,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,,,,,,,16.6,,,percent of total billed charges,,,16.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.33,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,15.44,,,percent of total billed charges,,,,,,,,,,,,,,,15.44,,,percent of total billed charges,,,15.44,,,percent of total billed charges,,,15.44,,,percent of total billed charges,,,12.45,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,11.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.78,,,percent of total billed charges,,
MONTELUKAST 4 MG CHEW TAB,2500014008,CDM,637,RC,3334211010,NDC,999,EAPG,,,,outpatient,facility,4,UN,16.6,16.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MONTELUKAST  SOD 10 MG TAB,2500014012,CDM,637,RC,1366808105,NDC,,,,,,inpatient,facility,10,UN,16.6,16.6,1.33,16.6,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,,,,,,,16.6,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.96,,,percent of total billed charges,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,14.11,,,percent of total billed charges,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,8.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,
MONTELUKAST  SOD 10 MG TAB,2500014012,CDM,637,RC,1366808105,NDC,,,,,,outpatient,facility,10,UN,16.6,16.6,1.33,548.68,,11.77,,,percent of total billed charges,,,4.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,16.6,,,percent of total billed charges,,,10.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,11.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,11.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,16.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,16.6,,,fee schedule,,,16.6,,,percent of total billed charges,,,,,,,,,16.6,,,percent of total billed charges,,,10.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.83,,,percent of total billed charges,,,,,,,,,,,,,,,8.96,,,percent of total billed charges,,,8.63,,,percent of total billed charges,,,9.13,,,percent of total billed charges,,,,,,,,,9.79,,,percent of total billed charges,,,548.68,,,per diem,,,16.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,16.6,,,percent of total billed charges,,,14.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.82,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.2,,,percent of total billed charges,,,13.43,,,percent of total billed charges,,,,,,,,,,,,,,,6.64,,,percent of total billed charges,,,,,,,,,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,,,,,,,16.6,,,percent of total billed charges,,,16.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.33,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,,,,,,,16.6,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,15.44,,,percent of total billed charges,,,,,,,,,,,,,,,15.44,,,percent of total billed charges,,,15.44,,,percent of total billed charges,,,15.44,,,percent of total billed charges,,,12.45,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,16.6,,,percent of total billed charges,,,,,,,,,11.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.78,,,percent of total billed charges,,
MONTELUKAST  SOD 10 MG TAB,2500014012,CDM,637,RC,1366808105,NDC,999,EAPG,,,,outpatient,facility,10,UN,16.6,16.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE SULF 10 MG/5 ML UDC,2500014042,CDM,637,RC,121090494,NDC,,,,,,inpatient,facility,5,UN,5.38,5.38,0.43,5.38,,,,,,,,,,,,,,5.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.38,,,percent of total billed charges,,,,,,,,,5.38,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,5.38,,,percent of total billed charges,,,4.57,,,percent of total billed charges,,,,,,,,,,,,,,,5.38,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.38,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,
MORPHINE SULF 10 MG/5 ML UDC,2500014042,CDM,637,RC,121090494,NDC,,,,,,outpatient,facility,5,UN,5.38,5.38,0.43,548.68,,3.81,,,percent of total billed charges,,,1.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.38,,,percent of total billed charges,,,3.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.97,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.38,,,fee schedule,,,5.38,,,percent of total billed charges,,,,,,,,,5.38,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,2.8,,,percent of total billed charges,,,2.96,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,548.68,,,per diem,,,5.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.38,,,percent of total billed charges,,,4.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.86,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,1.99,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,,,,,,,5.38,,,percent of total billed charges,,,5.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.43,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,,,,,,,,,,,,,5.38,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,,,,,,,5,,,percent of total billed charges,,,,,,,,,,,,,,,5,,,percent of total billed charges,,,5,,,percent of total billed charges,,,5,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,,,,,,,3.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.17,,,percent of total billed charges,,
MORPHINE SULF 10 MG/5 ML UDC,2500014042,CDM,637,RC,121090494,NDC,999,EAPG,,,,outpatient,facility,5,UN,5.38,5.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE SULF 15 MG TAB,2500014044,CDM,637,RC,54023524,NDC,,,,,,inpatient,facility,15,UN,3,3,0.24,3,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,3,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,
MORPHINE SULF 15 MG TAB,2500014044,CDM,637,RC,54023524,NDC,,,,,,outpatient,facility,15,UN,3,3,0.24,548.68,,2.13,,,percent of total billed charges,,,0.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3,,,percent of total billed charges,,,1.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3,,,fee schedule,,,3,,,percent of total billed charges,,,,,,,,,3,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,1.77,,,percent of total billed charges,,,548.68,,,per diem,,,3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.59,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,1.11,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,3,,,percent of total billed charges,,,3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,2.79,,,percent of total billed charges,,,2.79,,,percent of total billed charges,,,2.79,,,percent of total billed charges,,,2.25,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,2.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.77,,,percent of total billed charges,,
MORPHINE SULF 15 MG TAB,2500014044,CDM,637,RC,54023524,NDC,999,EAPG,,,,outpatient,facility,15,UN,3,3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE SULF SR 15 MG TAB,2500014061,CDM,637,RC,904655761,NDC,,,,,,inpatient,facility,15,UN,3.76,3.76,0.3,3.76,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,
MORPHINE SULF SR 15 MG TAB,2500014061,CDM,637,RC,904655761,NDC,,,,,,outpatient,facility,15,UN,3.76,3.76,0.3,548.68,,2.67,,,percent of total billed charges,,,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.76,,,percent of total billed charges,,,2.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.38,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.76,,,fee schedule,,,3.76,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,,,,,,,2.22,,,percent of total billed charges,,,548.68,,,per diem,,,3.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.76,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,1.39,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,2.82,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.22,,,percent of total billed charges,,
MORPHINE SULF SR 15 MG TAB,2500014061,CDM,637,RC,904655761,NDC,999,EAPG,,,,outpatient,facility,15,UN,3.76,3.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE SULF SR 30 MG TAB,2500014062,CDM,637,RC,904655861,NDC,,,,,,inpatient,facility,30,UN,4.12,4.12,0.33,4.12,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,4.12,,,percent of total billed charges,,,2.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,
MORPHINE SULF SR 30 MG TAB,2500014062,CDM,637,RC,904655861,NDC,,,,,,outpatient,facility,30,UN,4.12,4.12,0.33,548.68,,2.92,,,percent of total billed charges,,,1.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.12,,,percent of total billed charges,,,2.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.51,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.12,,,fee schedule,,,4.12,,,percent of total billed charges,,,,,,,,,4.12,,,percent of total billed charges,,,2.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.27,,,percent of total billed charges,,,,,,,,,2.43,,,percent of total billed charges,,,548.68,,,per diem,,,4.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.12,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.78,,,percent of total billed charges,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,4.12,,,percent of total billed charges,,,4.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.33,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,3.83,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,2.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.43,,,percent of total billed charges,,
MORPHINE SULF SR 30 MG TAB,2500014062,CDM,637,RC,904655861,NDC,999,EAPG,,,,outpatient,facility,30,UN,4.12,4.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MULTIVITAMINS INJ ADULT 10 ML,2500014079,CDM,250,RC,5464356491,NDC,,,,,,inpatient,facility,10,UN,50.75,50.75,4.06,50.75,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,,,,,,,50.75,,,percent of total billed charges,,,25.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.45,,,percent of total billed charges,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,43.14,,,percent of total billed charges,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,26.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.9,,,percent of total billed charges,,
MULTIVITAMINS INJ ADULT 10 ML,2500014079,CDM,250,RC,5464356491,NDC,,,,,,outpatient,facility,10,UN,50.75,50.75,4.06,548.68,,35.99,,,percent of total billed charges,,,12.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,50.75,,,percent of total billed charges,,,31.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,35.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,35.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,18.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,50.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,50.75,,,fee schedule,,,50.75,,,percent of total billed charges,,,,,,,,,50.75,,,percent of total billed charges,,,31.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,29.94,,,percent of total billed charges,,,548.68,,,per diem,,,50.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,50.75,,,percent of total billed charges,,,43.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.95,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.24,,,percent of total billed charges,,,41.07,,,percent of total billed charges,,,,,,,,,,,,,,,20.3,,,percent of total billed charges,,,,,,,,,20.3,,,percent of total billed charges,,,20.3,,,percent of total billed charges,,,,,,,,,50.75,,,percent of total billed charges,,,50.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,50.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.06,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,,,,,,,,,,,,,50.75,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,,,,,,,20.3,,,percent of total billed charges,,,,,,,,,,,,,,,20.3,,,percent of total billed charges,,,20.3,,,percent of total billed charges,,,20.3,,,percent of total billed charges,,,38.06,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,50.75,,,percent of total billed charges,,,,,,,,,35.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,29.9,,,percent of total billed charges,,
MULTIVITAMINS INJ ADULT 10 ML,2500014079,CDM,250,RC,5464356491,NDC,999,EAPG,,,,outpatient,facility,10,UN,50.75,50.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MULTIVITAMIN/MINERALS TAB,2500014098,CDM,637,RC,904549261,NDC,,,,,,inpatient,facility,1,UN,0.83,0.83,0.07,0.83,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,
MULTIVITAMIN/MINERALS TAB,2500014098,CDM,637,RC,904549261,NDC,,,,,,outpatient,facility,1,UN,0.83,0.83,0.07,548.68,,0.59,,,percent of total billed charges,,,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.83,,,percent of total billed charges,,,0.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.83,,,fee schedule,,,0.83,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,548.68,,,per diem,,,0.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.83,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,0.31,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,0.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.49,,,percent of total billed charges,,
MULTIVITAMIN/MINERALS TAB,2500014098,CDM,637,RC,904549261,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.83,0.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MUPIROCIN 2  OINT 22 GM,2500014122,CDM,637,RC,5167213120,NDC,,,,,,inpatient,facility,22,UN,82.5,82.5,6.6,82.5,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,82.5,,,percent of total billed charges,,,42.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,70.12,,,percent of total billed charges,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,43.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.61,,,percent of total billed charges,,
MUPIROCIN 2  OINT 22 GM,2500014122,CDM,637,RC,5167213120,NDC,,,,,,outpatient,facility,22,UN,82.5,82.5,6.6,548.68,,58.5,,,percent of total billed charges,,,20.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,82.5,,,percent of total billed charges,,,51.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,30.2,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,82.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,82.5,,,fee schedule,,,82.5,,,percent of total billed charges,,,,,,,,,82.5,,,percent of total billed charges,,,50.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.78,,,percent of total billed charges,,,,,,,,,,,,,,,44.55,,,percent of total billed charges,,,42.9,,,percent of total billed charges,,,45.38,,,percent of total billed charges,,,,,,,,,48.68,,,percent of total billed charges,,,548.68,,,per diem,,,82.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,82.5,,,percent of total billed charges,,,70.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.82,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.65,,,percent of total billed charges,,,66.76,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,30.52,,,percent of total billed charges,,,30.52,,,percent of total billed charges,,,,,,,,,82.5,,,percent of total billed charges,,,82.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,82.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.6,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,76.74,,,percent of total billed charges,,,,,,,,,,,,,,,76.74,,,percent of total billed charges,,,76.74,,,percent of total billed charges,,,76.74,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,82.5,,,percent of total billed charges,,,,,,,,,57.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,48.61,,,percent of total billed charges,,
MUPIROCIN 2  OINT 22 GM,2500014122,CDM,637,RC,5167213120,NDC,999,EAPG,,,,outpatient,facility,22,UN,82.5,82.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MUPIROCIN NASAL 2  1 GM,2500014125,CDM,637,RC,4580211222,NDC,,,,,,inpatient,facility,1,UN,1.35,1.35,0.11,1.35,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,
MUPIROCIN NASAL 2  1 GM,2500014125,CDM,637,RC,4580211222,NDC,,,,,,outpatient,facility,1,UN,1.35,1.35,0.11,548.68,,0.96,,,percent of total billed charges,,,0.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.35,,,percent of total billed charges,,,0.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.35,,,fee schedule,,,1.35,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,0.8,,,percent of total billed charges,,,548.68,,,per diem,,,1.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.35,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.8,,,percent of total billed charges,,
MUPIROCIN NASAL 2  1 GM,2500014125,CDM,637,RC,4580211222,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.35,1.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MUPIROCIN 2 CREAM 15 GM,2500014127,CDM,637,RC,6846256417,NDC,,,,,,inpatient,facility,15,UN,809.03,809.03,64.72,809.03,,,,,,,,,,,,,,809.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,809.03,,,percent of total billed charges,,,,,,,,,809.03,,,percent of total billed charges,,,413.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,689.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,485.42,,,percent of total billed charges,,,,,,,,,,,,,,,809.03,,,percent of total billed charges,,,687.68,,,percent of total billed charges,,,,,,,,,,,,,,,809.03,,,percent of total billed charges,,,429.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,809.03,,,percent of total billed charges,,,,,,,,,,,,,,,64.72,,,percent of total billed charges,,,809.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,809.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,476.68,,,percent of total billed charges,,
MUPIROCIN 2 CREAM 15 GM,2500014127,CDM,637,RC,6846256417,NDC,,,,,,outpatient,facility,15,UN,809.03,809.03,64.72,809.03,,573.68,,,percent of total billed charges,,,197.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,809.03,,,percent of total billed charges,,,507.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,568.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,568.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,809.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,296.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,809.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,809.03,,,fee schedule,,,809.03,,,percent of total billed charges,,,,,,,,,809.03,,,percent of total billed charges,,,495.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,576.43,,,percent of total billed charges,,,,,,,,,,,,,,,436.88,,,percent of total billed charges,,,420.7,,,percent of total billed charges,,,444.97,,,percent of total billed charges,,,,,,,,,477.33,,,percent of total billed charges,,,548.68,,,per diem,,,809.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,809.03,,,percent of total billed charges,,,687.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,429.68,,,percent of total billed charges,,,809.03,,,percent of total billed charges,,,809.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,545.77,,,percent of total billed charges,,,654.67,,,percent of total billed charges,,,,,,,,,,,,,,,323.61,,,percent of total billed charges,,,,,,,,,299.34,,,percent of total billed charges,,,299.34,,,percent of total billed charges,,,,,,,,,809.03,,,percent of total billed charges,,,809.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,809.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,64.72,,,percent of total billed charges,,,809.03,,,percent of total billed charges,,,,,,,,,,,,,,,809.03,,,percent of total billed charges,,,809.03,,,percent of total billed charges,,,,,,,,,752.56,,,percent of total billed charges,,,,,,,,,,,,,,,752.56,,,percent of total billed charges,,,752.56,,,percent of total billed charges,,,752.56,,,percent of total billed charges,,,606.77,,,percent of total billed charges,,,809.03,,,percent of total billed charges,,,809.03,,,percent of total billed charges,,,809.03,,,percent of total billed charges,,,,,,,,,567.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,476.68,,,percent of total billed charges,,
MUPIROCIN 2 CREAM 15 GM,2500014127,CDM,637,RC,6846256417,NDC,999,EAPG,,,,outpatient,facility,15,UN,809.03,809.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MYCOPHENOLATE 250 MG CAP,2500014150,CDM,636,RC,J7517,HCPCS,1672909401,NDC,,,,inpatient,facility,250,UN,12.93,12.93,1.03,12.93,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,,,,,,,12.93,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.76,,,percent of total billed charges,,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,10.99,,,percent of total billed charges,,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,6.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.62,,,percent of total billed charges,,
MYCOPHENOLATE 250 MG CAP,2500014150,CDM,636,RC,J7517,HCPCS,1672909401,NDC,,,,outpatient,facility,250,UN,12.93,12.93,0.17,548.68,,9.17,,,percent of total billed charges,,,3.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,12.93,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,12.93,,,fee schedule,,,12.93,,,percent of total billed charges,,,,,,,,,12.93,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.63,,,percent of total billed charges,,,548.68,,,per diem,,,12.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12.93,,,percent of total billed charges,,,10.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.87,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.72,,,percent of total billed charges,,,10.46,,,percent of total billed charges,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12.93,,,percent of total billed charges,,,12.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.03,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.17,,,fee schedule,,,12.93,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,12.93,,,percent of total billed charges,,,,,,,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.62,,,percent of total billed charges,,
MYCOPHENOLATE 250 MG CAP,2500014150,CDM,636,RC,J7517,HCPCS,1672909401,NDC,496,EAPG,,outpatient,facility,250,UN,12.93,12.93,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MYCOPHENOLATE 180 MG TAB,2500014152,CDM,637,RC,J7518,HCPCS,904678504,NDC,,,,inpatient,facility,180,UN,13.69,13.69,1.1,13.69,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,13.69,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.21,,,percent of total billed charges,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,11.64,,,percent of total billed charges,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,7.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.07,,,percent of total billed charges,,
MYCOPHENOLATE 180 MG TAB,2500014152,CDM,637,RC,J7518,HCPCS,904678504,NDC,,,,outpatient,facility,180,UN,13.69,13.69,0.39,548.68,,9.71,,,percent of total billed charges,,,3.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.69,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.69,,,fee schedule,,,13.69,,,percent of total billed charges,,,,,,,,,13.69,,,percent of total billed charges,,,8.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,8.08,,,percent of total billed charges,,,548.68,,,per diem,,,13.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.69,,,percent of total billed charges,,,11.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.27,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,11.08,,,percent of total billed charges,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13.69,,,percent of total billed charges,,,13.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.1,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.39,,,fee schedule,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,9.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.07,,,percent of total billed charges,,
MYCOPHENOLATE 180 MG TAB,2500014152,CDM,637,RC,J7518,HCPCS,904678504,NDC,496,EAPG,,outpatient,facility,180,UN,13.69,13.69,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NABUMETONE 500 MG TAB,2500014160,CDM,637,RC,6909796507,NDC,,,,,,inpatient,facility,500,UN,4.42,4.42,0.35,4.42,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,
NABUMETONE 500 MG TAB,2500014160,CDM,637,RC,6909796507,NDC,,,,,,outpatient,facility,500,UN,4.42,4.42,0.35,548.68,,3.13,,,percent of total billed charges,,,1.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.42,,,percent of total billed charges,,,2.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.62,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.42,,,fee schedule,,,4.42,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,2.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.15,,,percent of total billed charges,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,,,,,,,2.61,,,percent of total billed charges,,,548.68,,,per diem,,,4.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.42,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,1.64,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,4.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.35,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,4.11,,,percent of total billed charges,,,,,,,,,,,,,,,4.11,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.6,,,percent of total billed charges,,
NABUMETONE 500 MG TAB,2500014160,CDM,637,RC,6909796507,NDC,999,EAPG,,,,outpatient,facility,500,UN,4.42,4.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NALTREXONE HCL 50 MG TAB,2500014200,CDM,637,RC,4733532683,NDC,,,,,,inpatient,facility,50,UN,14.12,14.12,1.13,14.12,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,,,,,,,14.12,,,percent of total billed charges,,,7.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.47,,,percent of total billed charges,,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,7.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.32,,,percent of total billed charges,,
NALTREXONE HCL 50 MG TAB,2500014200,CDM,637,RC,4733532683,NDC,,,,,,outpatient,facility,50,UN,14.12,14.12,1.13,548.68,,10.01,,,percent of total billed charges,,,3.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.12,,,percent of total billed charges,,,8.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.17,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.12,,,fee schedule,,,14.12,,,percent of total billed charges,,,,,,,,,14.12,,,percent of total billed charges,,,8.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.06,,,percent of total billed charges,,,,,,,,,,,,,,,7.62,,,percent of total billed charges,,,7.34,,,percent of total billed charges,,,7.77,,,percent of total billed charges,,,,,,,,,8.33,,,percent of total billed charges,,,548.68,,,per diem,,,14.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.12,,,percent of total billed charges,,,12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.5,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.53,,,percent of total billed charges,,,11.43,,,percent of total billed charges,,,,,,,,,,,,,,,5.65,,,percent of total billed charges,,,,,,,,,5.22,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,,,,,,,14.12,,,percent of total billed charges,,,14.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.13,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,,,,,,,13.13,,,percent of total billed charges,,,,,,,,,,,,,,,13.13,,,percent of total billed charges,,,13.13,,,percent of total billed charges,,,13.13,,,percent of total billed charges,,,10.59,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.32,,,percent of total billed charges,,
NALTREXONE HCL 50 MG TAB,2500014200,CDM,637,RC,4733532683,NDC,999,EAPG,,,,outpatient,facility,50,UN,14.12,14.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAPHAZOLINE/PHENIRAM OPH 15ML,2500014230,CDM,637,RC,65008515,NDC,,,,,,inpatient,facility,15,UN,25.87,25.87,2.07,25.87,,,,,,,,,,,,,,25.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.87,,,percent of total billed charges,,,,,,,,,25.87,,,percent of total billed charges,,,13.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.52,,,percent of total billed charges,,,,,,,,,,,,,,,25.87,,,percent of total billed charges,,,21.99,,,percent of total billed charges,,,,,,,,,,,,,,,25.87,,,percent of total billed charges,,,13.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,25.87,,,percent of total billed charges,,,,,,,,,,,,,,,2.07,,,percent of total billed charges,,,25.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.24,,,percent of total billed charges,,
NAPHAZOLINE/PHENIRAM OPH 15ML,2500014230,CDM,637,RC,65008515,NDC,,,,,,outpatient,facility,15,UN,25.87,25.87,2.07,548.68,,18.34,,,percent of total billed charges,,,6.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,25.87,,,percent of total billed charges,,,16.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,18.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,18.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,25.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.47,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,25.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,25.87,,,fee schedule,,,25.87,,,percent of total billed charges,,,,,,,,,25.87,,,percent of total billed charges,,,15.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.43,,,percent of total billed charges,,,,,,,,,,,,,,,13.97,,,percent of total billed charges,,,13.45,,,percent of total billed charges,,,14.23,,,percent of total billed charges,,,,,,,,,15.26,,,percent of total billed charges,,,548.68,,,per diem,,,25.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,25.87,,,percent of total billed charges,,,21.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.74,,,percent of total billed charges,,,25.87,,,percent of total billed charges,,,25.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.45,,,percent of total billed charges,,,20.93,,,percent of total billed charges,,,,,,,,,,,,,,,10.35,,,percent of total billed charges,,,,,,,,,9.57,,,percent of total billed charges,,,9.57,,,percent of total billed charges,,,,,,,,,25.87,,,percent of total billed charges,,,25.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.07,,,percent of total billed charges,,,25.87,,,percent of total billed charges,,,,,,,,,,,,,,,25.87,,,percent of total billed charges,,,25.87,,,percent of total billed charges,,,,,,,,,24.06,,,percent of total billed charges,,,,,,,,,,,,,,,24.06,,,percent of total billed charges,,,24.06,,,percent of total billed charges,,,24.06,,,percent of total billed charges,,,19.4,,,percent of total billed charges,,,25.87,,,percent of total billed charges,,,25.87,,,percent of total billed charges,,,25.87,,,percent of total billed charges,,,,,,,,,18.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15.24,,,percent of total billed charges,,
NAPHAZOLINE/PHENIRAM OPH 15ML,2500014230,CDM,637,RC,65008515,NDC,999,EAPG,,,,outpatient,facility,15,UN,25.87,25.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAPROXEN 250 MG TAB,2500014240,CDM,637,RC,5026859415,NDC,,,,,,inpatient,facility,250,UN,2.57,2.57,0.21,2.57,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,2.57,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,
NAPROXEN 250 MG TAB,2500014240,CDM,637,RC,5026859415,NDC,,,,,,outpatient,facility,250,UN,2.57,2.57,0.21,548.68,,1.82,,,percent of total billed charges,,,0.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.57,,,percent of total billed charges,,,1.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.94,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.57,,,fee schedule,,,2.57,,,percent of total billed charges,,,,,,,,,2.57,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,548.68,,,per diem,,,2.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.57,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,2.57,,,percent of total billed charges,,,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.51,,,percent of total billed charges,,
NAPROXEN 250 MG TAB,2500014240,CDM,637,RC,5026859415,NDC,999,EAPG,,,,outpatient,facility,250,UN,2.57,2.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAPROXEN 375 MG TAB,2500014241,CDM,637,RC,6846218905,NDC,,,,,,inpatient,facility,375,UN,3.23,3.23,0.26,3.23,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,
NAPROXEN 375 MG TAB,2500014241,CDM,637,RC,6846218905,NDC,,,,,,outpatient,facility,375,UN,3.23,3.23,0.26,548.68,,2.29,,,percent of total billed charges,,,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.23,,,percent of total billed charges,,,2.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.23,,,fee schedule,,,3.23,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,1.91,,,percent of total billed charges,,,548.68,,,per diem,,,3.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.23,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,1.2,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,3.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.9,,,percent of total billed charges,,
NAPROXEN 375 MG TAB,2500014241,CDM,637,RC,6846218905,NDC,999,EAPG,,,,outpatient,facility,375,UN,3.23,3.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NAPROXEN 500 MG TAB,2500014243,CDM,637,RC,6846219005,NDC,,,,,,inpatient,facility,500,UN,3.93,3.93,0.31,3.93,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,,,,,,,3.93,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,3.34,,,percent of total billed charges,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,2.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,
NAPROXEN 500 MG TAB,2500014243,CDM,637,RC,6846219005,NDC,,,,,,outpatient,facility,500,UN,3.93,3.93,0.31,548.68,,2.79,,,percent of total billed charges,,,0.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.93,,,percent of total billed charges,,,2.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.93,,,fee schedule,,,3.93,,,percent of total billed charges,,,,,,,,,3.93,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,2.32,,,percent of total billed charges,,,548.68,,,per diem,,,3.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.93,,,percent of total billed charges,,,3.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.09,,,percent of total billed charges,,,3.93,,,percent of total billed charges,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,3.18,,,percent of total billed charges,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,1.45,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,3.93,,,percent of total billed charges,,,3.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.31,,,percent of total billed charges,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,3.93,,,percent of total billed charges,,,,,,,,,3.66,,,percent of total billed charges,,,,,,,,,,,,,,,3.66,,,percent of total billed charges,,,3.66,,,percent of total billed charges,,,3.66,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,3.93,,,percent of total billed charges,,,3.93,,,percent of total billed charges,,,3.93,,,percent of total billed charges,,,,,,,,,2.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.32,,,percent of total billed charges,,
NAPROXEN 500 MG TAB,2500014243,CDM,637,RC,6846219005,NDC,999,EAPG,,,,outpatient,facility,500,UN,3.93,3.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOMYCIN SULF 500 MG TAB,2500014283,CDM,637,RC,93117701,NDC,,,,,,inpatient,facility,500,UN,4.91,4.91,0.39,4.91,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,4.91,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,4.17,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,
NEOMYCIN SULF 500 MG TAB,2500014283,CDM,637,RC,93117701,NDC,,,,,,outpatient,facility,500,UN,4.91,4.91,0.39,548.68,,3.48,,,percent of total billed charges,,,1.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.91,,,percent of total billed charges,,,3.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.8,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.91,,,fee schedule,,,4.91,,,percent of total billed charges,,,,,,,,,4.91,,,percent of total billed charges,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,,,,,,,2.9,,,percent of total billed charges,,,548.68,,,per diem,,,4.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.91,,,percent of total billed charges,,,4.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,,3.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,1.82,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,4.91,,,percent of total billed charges,,,4.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.39,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,4.57,,,percent of total billed charges,,,,,,,,,,,,,,,4.57,,,percent of total billed charges,,,4.57,,,percent of total billed charges,,,4.57,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.89,,,percent of total billed charges,,
NEOMYCIN SULF 500 MG TAB,2500014283,CDM,637,RC,93117701,NDC,999,EAPG,,,,outpatient,facility,500,UN,4.91,4.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOMYCIN/POLY/BACI OINT 15 GM,2500014295,CDM,637,RC,472017934,NDC,,,,,,inpatient,facility,14,UN,17.79,17.79,1.42,17.79,,,,,,,,,,,,,,17.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.79,,,percent of total billed charges,,,,,,,,,17.79,,,percent of total billed charges,,,9.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.67,,,percent of total billed charges,,,,,,,,,,,,,,,17.79,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,,,,,,,,,,,,,17.79,,,percent of total billed charges,,,9.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,17.79,,,percent of total billed charges,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,17.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.48,,,percent of total billed charges,,
NEOMYCIN/POLY/BACI OINT 15 GM,2500014295,CDM,637,RC,472017934,NDC,,,,,,outpatient,facility,14,UN,17.79,17.79,1.42,548.68,,12.61,,,percent of total billed charges,,,4.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,17.79,,,percent of total billed charges,,,11.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,12.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,12.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,17.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.51,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,17.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,17.79,,,fee schedule,,,17.79,,,percent of total billed charges,,,,,,,,,17.79,,,percent of total billed charges,,,10.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.68,,,percent of total billed charges,,,,,,,,,,,,,,,9.61,,,percent of total billed charges,,,9.25,,,percent of total billed charges,,,9.78,,,percent of total billed charges,,,,,,,,,10.5,,,percent of total billed charges,,,548.68,,,per diem,,,17.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,17.79,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.45,,,percent of total billed charges,,,17.79,,,percent of total billed charges,,,17.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,,,,,,,,,,,,,7.12,,,percent of total billed charges,,,,,,,,,6.58,,,percent of total billed charges,,,6.58,,,percent of total billed charges,,,,,,,,,17.79,,,percent of total billed charges,,,17.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.42,,,percent of total billed charges,,,17.79,,,percent of total billed charges,,,,,,,,,,,,,,,17.79,,,percent of total billed charges,,,17.79,,,percent of total billed charges,,,,,,,,,16.55,,,percent of total billed charges,,,,,,,,,,,,,,,16.55,,,percent of total billed charges,,,16.55,,,percent of total billed charges,,,16.55,,,percent of total billed charges,,,13.34,,,percent of total billed charges,,,17.79,,,percent of total billed charges,,,17.79,,,percent of total billed charges,,,17.79,,,percent of total billed charges,,,,,,,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.48,,,percent of total billed charges,,
NEOMYCIN/POLY/BACI OINT 15 GM,2500014295,CDM,637,RC,472017934,NDC,999,EAPG,,,,outpatient,facility,14,UN,17.79,17.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOMYCIN/POLY/BACI/HC OP 3.5GM,2500014298,CDM,637,RC,2420878555,NDC,,,,,,inpatient,facility,3.5,UN,214.67,214.67,17.17,214.67,,,,,,,,,,,,,,214.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.67,,,percent of total billed charges,,,,,,,,,214.67,,,percent of total billed charges,,,109.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.8,,,percent of total billed charges,,,,,,,,,,,,,,,214.67,,,percent of total billed charges,,,182.47,,,percent of total billed charges,,,,,,,,,,,,,,,214.67,,,percent of total billed charges,,,114.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,214.67,,,percent of total billed charges,,,,,,,,,,,,,,,17.17,,,percent of total billed charges,,,214.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,214.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.48,,,percent of total billed charges,,
NEOMYCIN/POLY/BACI/HC OP 3.5GM,2500014298,CDM,637,RC,2420878555,NDC,,,,,,outpatient,facility,3.5,UN,214.67,214.67,17.17,548.68,,152.22,,,percent of total billed charges,,,52.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,214.67,,,percent of total billed charges,,,134.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,150.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,150.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,214.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,78.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,214.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,214.67,,,fee schedule,,,214.67,,,percent of total billed charges,,,,,,,,,214.67,,,percent of total billed charges,,,131.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.95,,,percent of total billed charges,,,,,,,,,,,,,,,115.92,,,percent of total billed charges,,,111.63,,,percent of total billed charges,,,118.07,,,percent of total billed charges,,,,,,,,,126.66,,,percent of total billed charges,,,548.68,,,per diem,,,214.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,214.67,,,percent of total billed charges,,,182.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.01,,,percent of total billed charges,,,214.67,,,percent of total billed charges,,,214.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.82,,,percent of total billed charges,,,173.71,,,percent of total billed charges,,,,,,,,,,,,,,,85.87,,,percent of total billed charges,,,,,,,,,79.43,,,percent of total billed charges,,,79.43,,,percent of total billed charges,,,,,,,,,214.67,,,percent of total billed charges,,,214.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,214.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.17,,,percent of total billed charges,,,214.67,,,percent of total billed charges,,,,,,,,,,,,,,,214.67,,,percent of total billed charges,,,214.67,,,percent of total billed charges,,,,,,,,,199.69,,,percent of total billed charges,,,,,,,,,,,,,,,199.69,,,percent of total billed charges,,,199.69,,,percent of total billed charges,,,199.69,,,percent of total billed charges,,,161,,,percent of total billed charges,,,214.67,,,percent of total billed charges,,,214.67,,,percent of total billed charges,,,214.67,,,percent of total billed charges,,,,,,,,,150.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.33,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,126.48,,,percent of total billed charges,,
NEOMYCIN/POLY/BACI/HC OP 3.5GM,2500014298,CDM,637,RC,2420878555,NDC,999,EAPG,,,,outpatient,facility,3.5,UN,214.67,214.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOMYCIN/POLY/HC OP SUSP 7.5ML,2500014302,CDM,637,RC,6131464175,NDC,,,,,,inpatient,facility,7.5,UN,561.83,561.83,44.95,561.83,,,,,,,,,,,,,,561.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,561.83,,,percent of total billed charges,,,,,,,,,561.83,,,percent of total billed charges,,,286.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,478.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.1,,,percent of total billed charges,,,,,,,,,,,,,,,561.83,,,percent of total billed charges,,,477.56,,,percent of total billed charges,,,,,,,,,,,,,,,561.83,,,percent of total billed charges,,,298.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,561.83,,,percent of total billed charges,,,,,,,,,,,,,,,44.95,,,percent of total billed charges,,,561.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,561.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.03,,,percent of total billed charges,,
NEOMYCIN/POLY/HC OP SUSP 7.5ML,2500014302,CDM,637,RC,6131464175,NDC,,,,,,outpatient,facility,7.5,UN,561.83,561.83,44.95,561.83,,398.39,,,percent of total billed charges,,,137.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,561.83,,,percent of total billed charges,,,352.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,394.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,394.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,561.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,205.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,561.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,561.83,,,fee schedule,,,561.83,,,percent of total billed charges,,,,,,,,,561.83,,,percent of total billed charges,,,344.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.3,,,percent of total billed charges,,,,,,,,,,,,,,,303.39,,,percent of total billed charges,,,292.15,,,percent of total billed charges,,,309.01,,,percent of total billed charges,,,,,,,,,331.48,,,percent of total billed charges,,,548.68,,,per diem,,,561.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,561.83,,,percent of total billed charges,,,477.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,298.39,,,percent of total billed charges,,,561.83,,,percent of total billed charges,,,561.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,379.01,,,percent of total billed charges,,,454.63,,,percent of total billed charges,,,,,,,,,,,,,,,224.73,,,percent of total billed charges,,,,,,,,,207.88,,,percent of total billed charges,,,207.88,,,percent of total billed charges,,,,,,,,,561.83,,,percent of total billed charges,,,561.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,561.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,44.95,,,percent of total billed charges,,,561.83,,,percent of total billed charges,,,,,,,,,,,,,,,561.83,,,percent of total billed charges,,,561.83,,,percent of total billed charges,,,,,,,,,522.61,,,percent of total billed charges,,,,,,,,,,,,,,,522.61,,,percent of total billed charges,,,522.61,,,percent of total billed charges,,,522.61,,,percent of total billed charges,,,421.37,,,percent of total billed charges,,,561.83,,,percent of total billed charges,,,561.83,,,percent of total billed charges,,,561.83,,,percent of total billed charges,,,,,,,,,393.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,331.03,,,percent of total billed charges,,
NEOMYCIN/POLY/HC OP SUSP 7.5ML,2500014302,CDM,637,RC,6131464175,NDC,999,EAPG,,,,outpatient,facility,7.5,UN,561.83,561.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOMYCIN/POLY/HC OTIC SUS 10ML,2500014304,CDM,637,RC,2420863562,NDC,,,,,,inpatient,facility,10,UN,276.87,276.87,22.15,276.87,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,276.87,,,percent of total billed charges,,,141.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.12,,,percent of total billed charges,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,235.34,,,percent of total billed charges,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,147.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,22.15,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.13,,,percent of total billed charges,,
NEOMYCIN/POLY/HC OTIC SUS 10ML,2500014304,CDM,637,RC,2420863562,NDC,,,,,,outpatient,facility,10,UN,276.87,276.87,22.15,548.68,,196.33,,,percent of total billed charges,,,67.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,276.87,,,percent of total billed charges,,,173.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,194.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,194.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,101.33,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,276.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,276.87,,,fee schedule,,,276.87,,,percent of total billed charges,,,,,,,,,276.87,,,percent of total billed charges,,,169.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.27,,,percent of total billed charges,,,,,,,,,,,,,,,149.51,,,percent of total billed charges,,,143.97,,,percent of total billed charges,,,152.28,,,percent of total billed charges,,,,,,,,,163.35,,,percent of total billed charges,,,548.68,,,per diem,,,276.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,276.87,,,percent of total billed charges,,,235.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,147.05,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.78,,,percent of total billed charges,,,224.04,,,percent of total billed charges,,,,,,,,,,,,,,,110.75,,,percent of total billed charges,,,,,,,,,102.44,,,percent of total billed charges,,,102.44,,,percent of total billed charges,,,,,,,,,276.87,,,percent of total billed charges,,,276.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,276.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.15,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,257.54,,,percent of total billed charges,,,,,,,,,,,,,,,257.54,,,percent of total billed charges,,,257.54,,,percent of total billed charges,,,257.54,,,percent of total billed charges,,,207.65,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,194.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,163.13,,,percent of total billed charges,,
NEOMYCIN/POLY/HC OTIC SUS 10ML,2500014304,CDM,637,RC,2420863562,NDC,999,EAPG,,,,outpatient,facility,10,UN,276.87,276.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOMYCIN/POLY/HC OTIC SOL 10ML,2500014306,CDM,637,RC,2420863562,NDC,,,,,,inpatient,facility,10,UN,276.87,276.87,22.15,276.87,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,276.87,,,percent of total billed charges,,,141.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.12,,,percent of total billed charges,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,235.34,,,percent of total billed charges,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,147.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,22.15,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.13,,,percent of total billed charges,,
NEOMYCIN/POLY/HC OTIC SOL 10ML,2500014306,CDM,637,RC,2420863562,NDC,,,,,,outpatient,facility,10,UN,276.87,276.87,22.15,548.68,,196.33,,,percent of total billed charges,,,67.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,276.87,,,percent of total billed charges,,,173.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,194.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,194.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,101.33,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,276.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,276.87,,,fee schedule,,,276.87,,,percent of total billed charges,,,,,,,,,276.87,,,percent of total billed charges,,,169.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.27,,,percent of total billed charges,,,,,,,,,,,,,,,149.51,,,percent of total billed charges,,,143.97,,,percent of total billed charges,,,152.28,,,percent of total billed charges,,,,,,,,,163.35,,,percent of total billed charges,,,548.68,,,per diem,,,276.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,276.87,,,percent of total billed charges,,,235.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,147.05,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.78,,,percent of total billed charges,,,224.04,,,percent of total billed charges,,,,,,,,,,,,,,,110.75,,,percent of total billed charges,,,,,,,,,102.44,,,percent of total billed charges,,,102.44,,,percent of total billed charges,,,,,,,,,276.87,,,percent of total billed charges,,,276.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,276.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.15,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,,,,,,,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,257.54,,,percent of total billed charges,,,,,,,,,,,,,,,257.54,,,percent of total billed charges,,,257.54,,,percent of total billed charges,,,257.54,,,percent of total billed charges,,,207.65,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,276.87,,,percent of total billed charges,,,,,,,,,194.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,163.13,,,percent of total billed charges,,
NEOMYCIN/POLY/HC OTIC SOL 10ML,2500014306,CDM,637,RC,2420863562,NDC,999,EAPG,,,,outpatient,facility,10,UN,276.87,276.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOMYCIN/POLY/DEX OP ONT 3.5GM,2500014321,CDM,637,RC,2420879535,NDC,,,,,,inpatient,facility,3.5,UN,65.54,65.54,5.24,65.54,,,,,,,,,,,,,,65.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.54,,,percent of total billed charges,,,,,,,,,65.54,,,percent of total billed charges,,,33.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.32,,,percent of total billed charges,,,,,,,,,,,,,,,65.54,,,percent of total billed charges,,,55.71,,,percent of total billed charges,,,,,,,,,,,,,,,65.54,,,percent of total billed charges,,,34.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,65.54,,,percent of total billed charges,,,,,,,,,,,,,,,5.24,,,percent of total billed charges,,,65.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.62,,,percent of total billed charges,,
NEOMYCIN/POLY/DEX OP ONT 3.5GM,2500014321,CDM,637,RC,2420879535,NDC,,,,,,outpatient,facility,3.5,UN,65.54,65.54,5.24,548.68,,46.47,,,percent of total billed charges,,,15.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,65.54,,,percent of total billed charges,,,41.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,46.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,46.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,65.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,23.99,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,65.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,65.54,,,fee schedule,,,65.54,,,percent of total billed charges,,,,,,,,,65.54,,,percent of total billed charges,,,40.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.7,,,percent of total billed charges,,,,,,,,,,,,,,,35.39,,,percent of total billed charges,,,34.08,,,percent of total billed charges,,,36.05,,,percent of total billed charges,,,,,,,,,38.67,,,percent of total billed charges,,,548.68,,,per diem,,,65.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,65.54,,,percent of total billed charges,,,55.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.81,,,percent of total billed charges,,,65.54,,,percent of total billed charges,,,65.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.21,,,percent of total billed charges,,,53.03,,,percent of total billed charges,,,,,,,,,,,,,,,26.22,,,percent of total billed charges,,,,,,,,,24.25,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,,,,,,,65.54,,,percent of total billed charges,,,65.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,65.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.24,,,percent of total billed charges,,,65.54,,,percent of total billed charges,,,,,,,,,,,,,,,65.54,,,percent of total billed charges,,,65.54,,,percent of total billed charges,,,,,,,,,60.97,,,percent of total billed charges,,,,,,,,,,,,,,,60.97,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,49.16,,,percent of total billed charges,,,65.54,,,percent of total billed charges,,,65.54,,,percent of total billed charges,,,65.54,,,percent of total billed charges,,,,,,,,,45.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,38.62,,,percent of total billed charges,,
NEOMYCIN/POLY/DEX OP ONT 3.5GM,2500014321,CDM,637,RC,2420879535,NDC,999,EAPG,,,,outpatient,facility,3.5,UN,65.54,65.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIACIN SR 250 MG CAP,2500014385,CDM,637,RC,1000670020,NDC,,,,,,inpatient,facility,250,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
NIACIN SR 250 MG CAP,2500014385,CDM,637,RC,1000670020,NDC,,,,,,outpatient,facility,250,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
NIACIN SR 250 MG CAP,2500014385,CDM,637,RC,1000670020,NDC,999,EAPG,,,,outpatient,facility,250,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIACIN SR 500 MG TAB,2500014387,CDM,637,RC,5026858315,NDC,,,,,,inpatient,facility,500,UN,1.6,1.6,0.13,1.6,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,1.6,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,
NIACIN SR 500 MG TAB,2500014387,CDM,637,RC,5026858315,NDC,,,,,,outpatient,facility,500,UN,1.6,1.6,0.13,548.68,,1.13,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.6,,,percent of total billed charges,,,1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.59,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.6,,,fee schedule,,,1.6,,,percent of total billed charges,,,,,,,,,1.6,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,,,,,,,0.94,,,percent of total billed charges,,,548.68,,,per diem,,,1.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.6,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,1.6,,,percent of total billed charges,,,1.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.94,,,percent of total billed charges,,
NIACIN SR 500 MG TAB,2500014387,CDM,637,RC,5026858315,NDC,999,EAPG,,,,outpatient,facility,500,UN,1.6,1.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NICARDIPINE HCL 25 MG/10ML AMP,2500014402,CDM,250,RC,517073510,NDC,,,,,,inpatient,facility,10,UN,101.44,101.44,8.12,101.44,,,,,,,,,,,,,,101.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.44,,,percent of total billed charges,,,,,,,,,101.44,,,percent of total billed charges,,,51.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.86,,,percent of total billed charges,,,,,,,,,,,,,,,101.44,,,percent of total billed charges,,,86.22,,,percent of total billed charges,,,,,,,,,,,,,,,101.44,,,percent of total billed charges,,,53.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,101.44,,,percent of total billed charges,,,,,,,,,,,,,,,8.12,,,percent of total billed charges,,,101.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,101.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.77,,,percent of total billed charges,,
NICARDIPINE HCL 25 MG/10ML AMP,2500014402,CDM,250,RC,517073510,NDC,,,,,,outpatient,facility,10,UN,101.44,101.44,8.12,548.68,,71.93,,,percent of total billed charges,,,24.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,101.44,,,percent of total billed charges,,,63.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,71.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,71.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,101.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,37.13,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,101.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,101.44,,,fee schedule,,,101.44,,,percent of total billed charges,,,,,,,,,101.44,,,percent of total billed charges,,,62.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,59.85,,,percent of total billed charges,,,548.68,,,per diem,,,101.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,101.44,,,percent of total billed charges,,,86.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.87,,,percent of total billed charges,,,101.44,,,percent of total billed charges,,,101.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.43,,,percent of total billed charges,,,82.09,,,percent of total billed charges,,,,,,,,,,,,,,,40.58,,,percent of total billed charges,,,,,,,,,40.58,,,percent of total billed charges,,,40.58,,,percent of total billed charges,,,,,,,,,101.44,,,percent of total billed charges,,,101.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,101.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.12,,,percent of total billed charges,,,101.44,,,percent of total billed charges,,,,,,,,,,,,,,,101.44,,,percent of total billed charges,,,101.44,,,percent of total billed charges,,,,,,,,,40.58,,,percent of total billed charges,,,,,,,,,,,,,,,40.58,,,percent of total billed charges,,,40.58,,,percent of total billed charges,,,40.58,,,percent of total billed charges,,,76.08,,,percent of total billed charges,,,101.44,,,percent of total billed charges,,,101.44,,,percent of total billed charges,,,101.44,,,percent of total billed charges,,,,,,,,,71.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,59.77,,,percent of total billed charges,,
NICARDIPINE HCL 25 MG/10ML AMP,2500014402,CDM,250,RC,517073510,NDC,999,EAPG,,,,outpatient,facility,10,UN,101.44,101.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NICARDIPINE HCL 30 MG CAP,2500014403,CDM,637,RC,4280650209,NDC,,,,,,inpatient,facility,30,UN,73.23,73.23,5.86,73.23,,,,,,,,,,,,,,73.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.23,,,percent of total billed charges,,,,,,,,,73.23,,,percent of total billed charges,,,37.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.94,,,percent of total billed charges,,,,,,,,,,,,,,,73.23,,,percent of total billed charges,,,62.25,,,percent of total billed charges,,,,,,,,,,,,,,,73.23,,,percent of total billed charges,,,38.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,73.23,,,percent of total billed charges,,,,,,,,,,,,,,,5.86,,,percent of total billed charges,,,73.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.15,,,percent of total billed charges,,
NICARDIPINE HCL 30 MG CAP,2500014403,CDM,637,RC,4280650209,NDC,,,,,,outpatient,facility,30,UN,73.23,73.23,5.86,548.68,,51.93,,,percent of total billed charges,,,17.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,73.23,,,percent of total billed charges,,,45.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,51.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,51.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,73.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,26.8,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,73.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,73.23,,,fee schedule,,,73.23,,,percent of total billed charges,,,,,,,,,73.23,,,percent of total billed charges,,,44.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.18,,,percent of total billed charges,,,,,,,,,,,,,,,39.54,,,percent of total billed charges,,,38.08,,,percent of total billed charges,,,40.28,,,percent of total billed charges,,,,,,,,,43.21,,,percent of total billed charges,,,548.68,,,per diem,,,73.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,73.23,,,percent of total billed charges,,,62.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.89,,,percent of total billed charges,,,73.23,,,percent of total billed charges,,,73.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.4,,,percent of total billed charges,,,59.26,,,percent of total billed charges,,,,,,,,,,,,,,,29.29,,,percent of total billed charges,,,,,,,,,27.1,,,percent of total billed charges,,,27.1,,,percent of total billed charges,,,,,,,,,73.23,,,percent of total billed charges,,,73.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,73.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.86,,,percent of total billed charges,,,73.23,,,percent of total billed charges,,,,,,,,,,,,,,,73.23,,,percent of total billed charges,,,73.23,,,percent of total billed charges,,,,,,,,,68.12,,,percent of total billed charges,,,,,,,,,,,,,,,68.12,,,percent of total billed charges,,,68.12,,,percent of total billed charges,,,68.12,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,73.23,,,percent of total billed charges,,,73.23,,,percent of total billed charges,,,73.23,,,percent of total billed charges,,,,,,,,,51.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.62,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,43.15,,,percent of total billed charges,,
NICARDIPINE HCL 30 MG CAP,2500014403,CDM,637,RC,4280650209,NDC,999,EAPG,,,,outpatient,facility,30,UN,73.23,73.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NICARDIPINE NS 20MG/200ML IV,2500014406,CDM,250,RC,143963410,NDC,,,,,,inpatient,facility,200,UN,181.85,181.85,14.55,181.85,,,,,,,,,,,,,,181.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.85,,,percent of total billed charges,,,,,,,,,181.85,,,percent of total billed charges,,,92.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.11,,,percent of total billed charges,,,,,,,,,,,,,,,181.85,,,percent of total billed charges,,,154.57,,,percent of total billed charges,,,,,,,,,,,,,,,181.85,,,percent of total billed charges,,,96.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,181.85,,,percent of total billed charges,,,,,,,,,,,,,,,14.55,,,percent of total billed charges,,,181.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,181.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.15,,,percent of total billed charges,,
NICARDIPINE NS 20MG/200ML IV,2500014406,CDM,250,RC,143963410,NDC,,,,,,outpatient,facility,200,UN,181.85,181.85,14.55,548.68,,128.95,,,percent of total billed charges,,,44.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,181.85,,,percent of total billed charges,,,113.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,127.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,127.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,181.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,66.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,181.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,181.85,,,fee schedule,,,181.85,,,percent of total billed charges,,,,,,,,,181.85,,,percent of total billed charges,,,111.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,107.29,,,percent of total billed charges,,,548.68,,,per diem,,,181.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,181.85,,,percent of total billed charges,,,154.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,96.58,,,percent of total billed charges,,,181.85,,,percent of total billed charges,,,181.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.68,,,percent of total billed charges,,,147.15,,,percent of total billed charges,,,,,,,,,,,,,,,72.74,,,percent of total billed charges,,,,,,,,,72.74,,,percent of total billed charges,,,72.74,,,percent of total billed charges,,,,,,,,,181.85,,,percent of total billed charges,,,181.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,181.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.55,,,percent of total billed charges,,,181.85,,,percent of total billed charges,,,,,,,,,,,,,,,181.85,,,percent of total billed charges,,,181.85,,,percent of total billed charges,,,,,,,,,72.74,,,percent of total billed charges,,,,,,,,,,,,,,,72.74,,,percent of total billed charges,,,72.74,,,percent of total billed charges,,,72.74,,,percent of total billed charges,,,136.39,,,percent of total billed charges,,,181.85,,,percent of total billed charges,,,181.85,,,percent of total billed charges,,,181.85,,,percent of total billed charges,,,,,,,,,127.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,107.15,,,percent of total billed charges,,
NICARDIPINE NS 20MG/200ML IV,2500014406,CDM,250,RC,143963410,NDC,999,EAPG,,,,outpatient,facility,200,UN,181.85,181.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NICOTINE 21MG/ 24 HR PATCH,2500014411,CDM,637,RC,536589688,NDC,,,,,,inpatient,facility,1,UN,2.56,2.56,0.2,2.56,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,,,,,,,2.56,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,
NICOTINE 21MG/ 24 HR PATCH,2500014411,CDM,637,RC,536589688,NDC,,,,,,outpatient,facility,1,UN,2.56,2.56,0.2,548.68,,1.82,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.56,,,percent of total billed charges,,,1.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.94,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.56,,,fee schedule,,,2.56,,,percent of total billed charges,,,,,,,,,2.56,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,1.51,,,percent of total billed charges,,,548.68,,,per diem,,,2.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.56,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,2.56,,,percent of total billed charges,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,2.56,,,percent of total billed charges,,,2.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,2.56,,,percent of total billed charges,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,2.56,,,percent of total billed charges,,,2.56,,,percent of total billed charges,,,2.56,,,percent of total billed charges,,,,,,,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.51,,,percent of total billed charges,,
NICOTINE 21MG/ 24 HR PATCH,2500014411,CDM,637,RC,536589688,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.56,2.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NICOTINE 7 MG /24HR PATCH,2500014412,CDM,637,RC,536589488,NDC,,,,,,inpatient,facility,1,UN,2.57,2.57,0.21,2.57,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,2.57,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.51,,,percent of total billed charges,,
NICOTINE 7 MG /24HR PATCH,2500014412,CDM,637,RC,536589488,NDC,,,,,,outpatient,facility,1,UN,2.57,2.57,0.21,548.68,,1.82,,,percent of total billed charges,,,0.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.57,,,percent of total billed charges,,,1.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.94,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.57,,,fee schedule,,,2.57,,,percent of total billed charges,,,,,,,,,2.57,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,548.68,,,per diem,,,2.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.57,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,2.57,,,percent of total billed charges,,,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,2.39,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.51,,,percent of total billed charges,,
NICOTINE 7 MG /24HR PATCH,2500014412,CDM,637,RC,536589488,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.57,2.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NICOTINE POLACRILEX 2 MG GUM,2500014415,CDM,637,RC,536311201,NDC,,,,,,inpatient,facility,2,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
NICOTINE POLACRILEX 2 MG GUM,2500014415,CDM,637,RC,536311201,NDC,,,,,,outpatient,facility,2,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
NICOTINE POLACRILEX 2 MG GUM,2500014415,CDM,637,RC,536311201,NDC,999,EAPG,,,,outpatient,facility,2,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NICOTINE POLACRILEX 4 MG GUM,2500014416,CDM,637,RC,536303023,NDC,,,,,,inpatient,facility,4,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
NICOTINE POLACRILEX 4 MG GUM,2500014416,CDM,637,RC,536303023,NDC,,,,,,outpatient,facility,4,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
NICOTINE POLACRILEX 4 MG GUM,2500014416,CDM,637,RC,536303023,NDC,999,EAPG,,,,outpatient,facility,4,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NICOTINE POLACRILEX 2 MG LOZ.,2500014418,CDM,637,RC,4580234405,NDC,,,,,,inpatient,facility,2,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
NICOTINE POLACRILEX 2 MG LOZ.,2500014418,CDM,637,RC,4580234405,NDC,,,,,,outpatient,facility,2,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
NICOTINE POLACRILEX 2 MG LOZ.,2500014418,CDM,637,RC,4580234405,NDC,999,EAPG,,,,outpatient,facility,2,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIFEDIPINE 10 MG CAP,2500014420,CDM,637,RC,2315519401,NDC,,,,,,inpatient,facility,10,UN,3.53,3.53,0.28,3.53,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,3.53,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,
NIFEDIPINE 10 MG CAP,2500014420,CDM,637,RC,2315519401,NDC,,,,,,outpatient,facility,10,UN,3.53,3.53,0.28,548.68,,2.5,,,percent of total billed charges,,,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.53,,,percent of total billed charges,,,2.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.53,,,fee schedule,,,3.53,,,percent of total billed charges,,,,,,,,,3.53,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,548.68,,,per diem,,,3.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.53,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,1.31,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,3.53,,,percent of total billed charges,,,3.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,3.28,,,percent of total billed charges,,,3.28,,,percent of total billed charges,,,3.28,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.08,,,percent of total billed charges,,
NIFEDIPINE 10 MG CAP,2500014420,CDM,637,RC,2315519401,NDC,999,EAPG,,,,outpatient,facility,10,UN,3.53,3.53,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIFEDIPINE 30 MG TABCR,2500014423,CDM,637,RC,5074262001,NDC,,,,,,inpatient,facility,30,UN,4.58,4.58,0.37,4.58,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,,,,,,,4.58,,,percent of total billed charges,,,2.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,
NIFEDIPINE 30 MG TABCR,2500014423,CDM,637,RC,5074262001,NDC,,,,,,outpatient,facility,30,UN,4.58,4.58,0.37,548.68,,3.25,,,percent of total billed charges,,,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.58,,,percent of total billed charges,,,2.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.68,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.58,,,fee schedule,,,4.58,,,percent of total billed charges,,,,,,,,,4.58,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,2.7,,,percent of total billed charges,,,548.68,,,per diem,,,4.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.58,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.09,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,,,,,,,,1.69,,,percent of total billed charges,,,1.69,,,percent of total billed charges,,,,,,,,,4.58,,,percent of total billed charges,,,4.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.37,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,,,,,,,4.26,,,percent of total billed charges,,,,,,,,,,,,,,,4.26,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,4.26,,,percent of total billed charges,,,3.44,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,4.58,,,percent of total billed charges,,,,,,,,,3.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.7,,,percent of total billed charges,,
NIFEDIPINE 30 MG TABCR,2500014423,CDM,637,RC,5074262001,NDC,999,EAPG,,,,outpatient,facility,30,UN,4.58,4.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIFEDIPINE 60 MG TABCR,2500014424,CDM,637,RC,5074226101,NDC,,,,,,inpatient,facility,60,UN,7.56,7.56,0.6,7.56,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,,,,,,,7.56,,,percent of total billed charges,,,3.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.54,,,percent of total billed charges,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,
NIFEDIPINE 60 MG TABCR,2500014424,CDM,637,RC,5074226101,NDC,,,,,,outpatient,facility,60,UN,7.56,7.56,0.6,548.68,,5.36,,,percent of total billed charges,,,1.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.56,,,percent of total billed charges,,,4.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.77,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.56,,,fee schedule,,,7.56,,,percent of total billed charges,,,,,,,,,7.56,,,percent of total billed charges,,,4.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.39,,,percent of total billed charges,,,,,,,,,,,,,,,4.08,,,percent of total billed charges,,,3.93,,,percent of total billed charges,,,4.16,,,percent of total billed charges,,,,,,,,,4.46,,,percent of total billed charges,,,548.68,,,per diem,,,7.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.56,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.02,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.1,,,percent of total billed charges,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,3.02,,,percent of total billed charges,,,,,,,,,2.8,,,percent of total billed charges,,,2.8,,,percent of total billed charges,,,,,,,,,7.56,,,percent of total billed charges,,,7.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.6,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,,,,,,,,,,,,,7.56,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,,,,,,,5.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.45,,,percent of total billed charges,,
NIFEDIPINE 60 MG TABCR,2500014424,CDM,637,RC,5074226101,NDC,999,EAPG,,,,outpatient,facility,60,UN,7.56,7.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROFURANTOIN MONO 100 MG CAP,2500014464,CDM,637,RC,4778130301,NDC,,,,,,inpatient,facility,100,UN,12.57,12.57,1.01,12.57,,,,,,,,,,,,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.57,,,percent of total billed charges,,,,,,,,,12.57,,,percent of total billed charges,,,6.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.54,,,percent of total billed charges,,,,,,,,,,,,,,,12.57,,,percent of total billed charges,,,10.68,,,percent of total billed charges,,,,,,,,,,,,,,,12.57,,,percent of total billed charges,,,6.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.41,,,percent of total billed charges,,
NITROFURANTOIN MONO 100 MG CAP,2500014464,CDM,637,RC,4778130301,NDC,,,,,,outpatient,facility,100,UN,12.57,12.57,1.01,548.68,,8.91,,,percent of total billed charges,,,3.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,12.57,,,percent of total billed charges,,,7.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.6,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,12.57,,,fee schedule,,,12.57,,,percent of total billed charges,,,,,,,,,12.57,,,percent of total billed charges,,,7.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.96,,,percent of total billed charges,,,,,,,,,,,,,,,6.79,,,percent of total billed charges,,,6.54,,,percent of total billed charges,,,6.91,,,percent of total billed charges,,,,,,,,,7.42,,,percent of total billed charges,,,548.68,,,per diem,,,12.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12.57,,,percent of total billed charges,,,10.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.68,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.48,,,percent of total billed charges,,,10.17,,,percent of total billed charges,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,,,,,,,4.65,,,percent of total billed charges,,,4.65,,,percent of total billed charges,,,,,,,,,12.57,,,percent of total billed charges,,,12.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.01,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,12.57,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,,,,,,,11.69,,,percent of total billed charges,,,,,,,,,,,,,,,11.69,,,percent of total billed charges,,,11.69,,,percent of total billed charges,,,11.69,,,percent of total billed charges,,,9.43,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,,,,,,,8.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.41,,,percent of total billed charges,,
NITROFURANTOIN MONO 100 MG CAP,2500014464,CDM,637,RC,4778130301,NDC,999,EAPG,,,,outpatient,facility,100,UN,12.57,12.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 0.1 MG PATCH,2500014470,CDM,637,RC,378910293,NDC,,,,,,inpatient,facility,1,UN,6.14,6.14,0.49,6.14,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,,,,,,,6.14,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.62,,,percent of total billed charges,,
NITROGLYCERIN 0.1 MG PATCH,2500014470,CDM,637,RC,378910293,NDC,,,,,,outpatient,facility,1,UN,6.14,6.14,0.49,548.68,,4.35,,,percent of total billed charges,,,1.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.14,,,percent of total billed charges,,,3.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.14,,,fee schedule,,,6.14,,,percent of total billed charges,,,,,,,,,6.14,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,3.32,,,percent of total billed charges,,,3.19,,,percent of total billed charges,,,3.38,,,percent of total billed charges,,,,,,,,,3.62,,,percent of total billed charges,,,548.68,,,per diem,,,6.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.14,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.26,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.14,,,percent of total billed charges,,,4.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,2.27,,,percent of total billed charges,,,2.27,,,percent of total billed charges,,,,,,,,,6.14,,,percent of total billed charges,,,6.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.49,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,,,,,,,5.71,,,percent of total billed charges,,,,,,,,,,,,,,,5.71,,,percent of total billed charges,,,5.71,,,percent of total billed charges,,,5.71,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,,,,,,,4.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.62,,,percent of total billed charges,,
NITROGLYCERIN 0.1 MG PATCH,2500014470,CDM,637,RC,378910293,NDC,999,EAPG,,,,outpatient,facility,1,UN,6.14,6.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 0.2 MG PATCH,2500014472,CDM,637,RC,378910493,NDC,,,,,,inpatient,facility,1,UN,6.27,6.27,0.5,6.27,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,,,,,,,6.27,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,5.33,,,percent of total billed charges,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.69,,,percent of total billed charges,,
NITROGLYCERIN 0.2 MG PATCH,2500014472,CDM,637,RC,378910493,NDC,,,,,,outpatient,facility,1,UN,6.27,6.27,0.5,548.68,,4.45,,,percent of total billed charges,,,1.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.27,,,percent of total billed charges,,,3.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.27,,,fee schedule,,,6.27,,,percent of total billed charges,,,,,,,,,6.27,,,percent of total billed charges,,,3.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.47,,,percent of total billed charges,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,3.26,,,percent of total billed charges,,,3.45,,,percent of total billed charges,,,,,,,,,3.7,,,percent of total billed charges,,,548.68,,,per diem,,,6.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.27,,,percent of total billed charges,,,5.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.33,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.23,,,percent of total billed charges,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,2.32,,,percent of total billed charges,,,2.32,,,percent of total billed charges,,,,,,,,,6.27,,,percent of total billed charges,,,6.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.5,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,,,,,,,5.83,,,percent of total billed charges,,,,,,,,,,,,,,,5.83,,,percent of total billed charges,,,5.83,,,percent of total billed charges,,,5.83,,,percent of total billed charges,,,4.7,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,,,,,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.69,,,percent of total billed charges,,
NITROGLYCERIN 0.2 MG PATCH,2500014472,CDM,637,RC,378910493,NDC,999,EAPG,,,,outpatient,facility,1,UN,6.27,6.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 0.3 MG SL TAB,2500014473,CDM,637,RC,5976249211,NDC,,,,,,inpatient,facility,0.3,UN,1.25,1.25,0.1,1.25,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,
NITROGLYCERIN 0.3 MG SL TAB,2500014473,CDM,637,RC,5976249211,NDC,,,,,,outpatient,facility,0.3,UN,1.25,1.25,0.1,548.68,,0.89,,,percent of total billed charges,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.25,,,percent of total billed charges,,,0.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.25,,,fee schedule,,,1.25,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,548.68,,,per diem,,,1.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.25,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.74,,,percent of total billed charges,,
NITROGLYCERIN 0.3 MG SL TAB,2500014473,CDM,637,RC,5976249211,NDC,999,EAPG,,,,outpatient,facility,0.3,UN,1.25,1.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 0.3 MG PATCH,2500014474,CDM,637,RC,5074251530,NDC,,,,,,inpatient,facility,1,UN,209.85,209.85,16.79,209.85,,,,,,,,,,,,,,209.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.85,,,percent of total billed charges,,,,,,,,,209.85,,,percent of total billed charges,,,107.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.91,,,percent of total billed charges,,,,,,,,,,,,,,,209.85,,,percent of total billed charges,,,178.37,,,percent of total billed charges,,,,,,,,,,,,,,,209.85,,,percent of total billed charges,,,111.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,209.85,,,percent of total billed charges,,,,,,,,,,,,,,,16.79,,,percent of total billed charges,,,209.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,209.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.64,,,percent of total billed charges,,
NITROGLYCERIN 0.3 MG PATCH,2500014474,CDM,637,RC,5074251530,NDC,,,,,,outpatient,facility,1,UN,209.85,209.85,16.79,548.68,,148.8,,,percent of total billed charges,,,51.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,209.85,,,percent of total billed charges,,,131.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,147.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,147.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,209.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,76.81,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,209.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,209.85,,,fee schedule,,,209.85,,,percent of total billed charges,,,,,,,,,209.85,,,percent of total billed charges,,,128.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.52,,,percent of total billed charges,,,,,,,,,,,,,,,113.32,,,percent of total billed charges,,,109.12,,,percent of total billed charges,,,115.42,,,percent of total billed charges,,,,,,,,,123.81,,,percent of total billed charges,,,548.68,,,per diem,,,209.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,209.85,,,percent of total billed charges,,,178.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,111.45,,,percent of total billed charges,,,209.85,,,percent of total billed charges,,,209.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.56,,,percent of total billed charges,,,169.81,,,percent of total billed charges,,,,,,,,,,,,,,,83.94,,,percent of total billed charges,,,,,,,,,77.64,,,percent of total billed charges,,,77.64,,,percent of total billed charges,,,,,,,,,209.85,,,percent of total billed charges,,,209.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,209.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.79,,,percent of total billed charges,,,209.85,,,percent of total billed charges,,,,,,,,,,,,,,,209.85,,,percent of total billed charges,,,209.85,,,percent of total billed charges,,,,,,,,,195.2,,,percent of total billed charges,,,,,,,,,,,,,,,195.2,,,percent of total billed charges,,,195.2,,,percent of total billed charges,,,195.2,,,percent of total billed charges,,,157.39,,,percent of total billed charges,,,209.85,,,percent of total billed charges,,,209.85,,,percent of total billed charges,,,209.85,,,percent of total billed charges,,,,,,,,,147.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,123.64,,,percent of total billed charges,,
NITROGLYCERIN 0.3 MG PATCH,2500014474,CDM,637,RC,5074251530,NDC,999,EAPG,,,,outpatient,facility,1,UN,209.85,209.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 0.4 MG SL TAB,2500014475,CDM,637,RC,5976233043,NDC,,,,,,inpatient,facility,0.4,UN,1.25,1.25,0.1,1.25,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,
NITROGLYCERIN 0.4 MG SL TAB,2500014475,CDM,637,RC,5976233043,NDC,,,,,,outpatient,facility,0.4,UN,1.25,1.25,0.1,548.68,,0.89,,,percent of total billed charges,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.25,,,percent of total billed charges,,,0.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.25,,,fee schedule,,,1.25,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,548.68,,,per diem,,,1.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.25,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.74,,,percent of total billed charges,,
NITROGLYCERIN 0.4 MG SL TAB,2500014475,CDM,637,RC,5976233043,NDC,999,EAPG,,,,outpatient,facility,0.4,UN,1.25,1.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 0.4 MG PATCH,2500014476,CDM,637,RC,378911293,NDC,,,,,,inpatient,facility,1,UN,7.16,7.16,0.57,7.16,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,7.16,,,percent of total billed charges,,,3.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,6.09,,,percent of total billed charges,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,
NITROGLYCERIN 0.4 MG PATCH,2500014476,CDM,637,RC,378911293,NDC,,,,,,outpatient,facility,1,UN,7.16,7.16,0.57,548.68,,5.08,,,percent of total billed charges,,,1.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.16,,,percent of total billed charges,,,4.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.62,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.16,,,fee schedule,,,7.16,,,percent of total billed charges,,,,,,,,,7.16,,,percent of total billed charges,,,4.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.1,,,percent of total billed charges,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,3.72,,,percent of total billed charges,,,3.94,,,percent of total billed charges,,,,,,,,,4.22,,,percent of total billed charges,,,548.68,,,per diem,,,7.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.16,,,percent of total billed charges,,,6.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.83,,,percent of total billed charges,,,5.79,,,percent of total billed charges,,,,,,,,,,,,,,,2.86,,,percent of total billed charges,,,,,,,,,2.65,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,,,,,,,7.16,,,percent of total billed charges,,,7.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.57,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,7.16,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,6.66,,,percent of total billed charges,,,,,,,,,,,,,,,6.66,,,percent of total billed charges,,,6.66,,,percent of total billed charges,,,6.66,,,percent of total billed charges,,,5.37,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.22,,,percent of total billed charges,,
NITROGLYCERIN 0.4 MG PATCH,2500014476,CDM,637,RC,378911293,NDC,999,EAPG,,,,outpatient,facility,1,UN,7.16,7.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 0.6 MG PATCH,2500014481,CDM,637,RC,378911693,NDC,,,,,,inpatient,facility,1,UN,7.92,7.92,0.63,7.92,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,7.92,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,6.73,,,percent of total billed charges,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.67,,,percent of total billed charges,,
NITROGLYCERIN 0.6 MG PATCH,2500014481,CDM,637,RC,378911693,NDC,,,,,,outpatient,facility,1,UN,7.92,7.92,0.63,548.68,,5.62,,,percent of total billed charges,,,1.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.92,,,percent of total billed charges,,,4.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.9,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.92,,,fee schedule,,,7.92,,,percent of total billed charges,,,,,,,,,7.92,,,percent of total billed charges,,,4.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,4.36,,,percent of total billed charges,,,,,,,,,4.67,,,percent of total billed charges,,,548.68,,,per diem,,,7.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.92,,,percent of total billed charges,,,6.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.21,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.34,,,percent of total billed charges,,,6.41,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,7.92,,,percent of total billed charges,,,7.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.63,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,7.37,,,percent of total billed charges,,,,,,,,,,,,,,,7.37,,,percent of total billed charges,,,7.37,,,percent of total billed charges,,,7.37,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,5.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.67,,,percent of total billed charges,,
NITROGLYCERIN 0.6 MG PATCH,2500014481,CDM,637,RC,378911693,NDC,999,EAPG,,,,outpatient,facility,1,UN,7.92,7.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 0.8 MG/HR TDSY,2500014482,CDM,637,RC,5074251830,NDC,,,,,,inpatient,facility,1,UN,227.57,227.57,18.21,227.57,,,,,,,,,,,,,,227.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.57,,,percent of total billed charges,,,,,,,,,227.57,,,percent of total billed charges,,,116.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.54,,,percent of total billed charges,,,,,,,,,,,,,,,227.57,,,percent of total billed charges,,,193.43,,,percent of total billed charges,,,,,,,,,,,,,,,227.57,,,percent of total billed charges,,,120.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,227.57,,,percent of total billed charges,,,,,,,,,,,,,,,18.21,,,percent of total billed charges,,,227.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,227.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.08,,,percent of total billed charges,,
NITROGLYCERIN 0.8 MG/HR TDSY,2500014482,CDM,637,RC,5074251830,NDC,,,,,,outpatient,facility,1,UN,227.57,227.57,18.21,548.68,,161.37,,,percent of total billed charges,,,55.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,227.57,,,percent of total billed charges,,,142.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,159.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,159.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,227.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,83.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,227.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,227.57,,,fee schedule,,,227.57,,,percent of total billed charges,,,,,,,,,227.57,,,percent of total billed charges,,,139.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.14,,,percent of total billed charges,,,,,,,,,,,,,,,122.89,,,percent of total billed charges,,,118.34,,,percent of total billed charges,,,125.16,,,percent of total billed charges,,,,,,,,,134.27,,,percent of total billed charges,,,548.68,,,per diem,,,227.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,227.57,,,percent of total billed charges,,,193.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,120.86,,,percent of total billed charges,,,227.57,,,percent of total billed charges,,,227.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.52,,,percent of total billed charges,,,184.15,,,percent of total billed charges,,,,,,,,,,,,,,,91.03,,,percent of total billed charges,,,,,,,,,84.2,,,percent of total billed charges,,,84.2,,,percent of total billed charges,,,,,,,,,227.57,,,percent of total billed charges,,,227.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,227.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.21,,,percent of total billed charges,,,227.57,,,percent of total billed charges,,,,,,,,,,,,,,,227.57,,,percent of total billed charges,,,227.57,,,percent of total billed charges,,,,,,,,,211.69,,,percent of total billed charges,,,,,,,,,,,,,,,211.69,,,percent of total billed charges,,,211.69,,,percent of total billed charges,,,211.69,,,percent of total billed charges,,,170.68,,,percent of total billed charges,,,227.57,,,percent of total billed charges,,,227.57,,,percent of total billed charges,,,227.57,,,percent of total billed charges,,,,,,,,,159.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,134.08,,,percent of total billed charges,,
NITROGLYCERIN 0.8 MG/HR TDSY,2500014482,CDM,637,RC,5074251830,NDC,999,EAPG,,,,outpatient,facility,1,UN,227.57,227.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 2.5 MG CAPCR,2500014485,CDM,637,RC,4948322110,NDC,,,,,,inpatient,facility,2.5,UN,2.28,2.28,0.18,2.28,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,2.28,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,
NITROGLYCERIN 2.5 MG CAPCR,2500014485,CDM,637,RC,4948322110,NDC,,,,,,outpatient,facility,2.5,UN,2.28,2.28,0.18,548.68,,1.62,,,percent of total billed charges,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.28,,,percent of total billed charges,,,1.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.83,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.28,,,fee schedule,,,2.28,,,percent of total billed charges,,,,,,,,,2.28,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,548.68,,,per diem,,,2.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.28,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,,,,,,,0.84,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,2.28,,,percent of total billed charges,,,2.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.34,,,percent of total billed charges,,
NITROGLYCERIN 2.5 MG CAPCR,2500014485,CDM,637,RC,4948322110,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,2.28,2.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 5 MG/ML 10ML INJ,2500014487,CDM,250,RC,J3490,HCPCS,517481025,NDC,,,,inpatient,facility,10,UN,47.09,47.09,3.77,47.09,,,,,,,,,,,,,,47.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.09,,,percent of total billed charges,,,,,,,,,47.09,,,percent of total billed charges,,,24.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,,,,,,,,,,,,,47.09,,,percent of total billed charges,,,40.03,,,percent of total billed charges,,,,,,,,,,,,,,,47.09,,,percent of total billed charges,,,25.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,47.09,,,percent of total billed charges,,,,,,,,,,,,,,,3.77,,,percent of total billed charges,,,47.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.75,,,percent of total billed charges,,
NITROGLYCERIN 5 MG/ML 10ML INJ,2500014487,CDM,250,RC,J3490,HCPCS,517481025,NDC,,,,outpatient,facility,10,UN,47.09,47.09,1.2,548.68,,33.39,,,percent of total billed charges,,,11.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,47.09,,,percent of total billed charges,,,29.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,33.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,33.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,47.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,17.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,47.09,,,fee schedule,,,47.09,,,percent of total billed charges,,,,,,,,,47.09,,,percent of total billed charges,,,28.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.55,,,percent of total billed charges,,,,,,,,,,,,,,,47.09,,,percent of total billed charges,,,47.09,,,percent of total billed charges,,,47.09,,,percent of total billed charges,,,,,,,,,27.78,,,percent of total billed charges,,,548.68,,,per diem,,,47.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,47.09,,,percent of total billed charges,,,40.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.01,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.77,,,percent of total billed charges,,,38.11,,,percent of total billed charges,,,,,,,,,,,,,,,18.84,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,47.09,,,percent of total billed charges,,,47.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,47.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.77,,,percent of total billed charges,,,47.09,,,percent of total billed charges,,,,,,,,,,,,,,,47.09,,,percent of total billed charges,,,47.09,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,35.32,,,percent of total billed charges,,,47.09,,,percent of total billed charges,,,47.09,,,percent of total billed charges,,,47.09,,,percent of total billed charges,,,,,,,,,33.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,27.75,,,percent of total billed charges,,
NITROGLYCERIN 5 MG/ML 10ML INJ,2500014487,CDM,250,RC,J3490,HCPCS,517481025,NDC,435,EAPG,,outpatient,facility,10,UN,47.09,47.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN 2  OINT 1 GM PKT,2500014488,CDM,637,RC,281032608,NDC,,,,,,inpatient,facility,1,UN,10,10,0.8,10,,,,,,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,10,,,percent of total billed charges,,,5.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6,,,percent of total billed charges,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,8.5,,,percent of total billed charges,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,5.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.89,,,percent of total billed charges,,
NITROGLYCERIN 2  OINT 1 GM PKT,2500014488,CDM,637,RC,281032608,NDC,,,,,,outpatient,facility,1,UN,10,10,0.8,548.68,,7.09,,,percent of total billed charges,,,2.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10,,,percent of total billed charges,,,6.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.66,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10,,,fee schedule,,,10,,,percent of total billed charges,,,,,,,,,10,,,percent of total billed charges,,,6.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,5.4,,,percent of total billed charges,,,5.2,,,percent of total billed charges,,,5.5,,,percent of total billed charges,,,,,,,,,5.9,,,percent of total billed charges,,,548.68,,,per diem,,,10,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10,,,percent of total billed charges,,,8.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,10,,,percent of total billed charges,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.75,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,4,,,percent of total billed charges,,,,,,,,,3.7,,,percent of total billed charges,,,3.7,,,percent of total billed charges,,,,,,,,,10,,,percent of total billed charges,,,10,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.8,,,percent of total billed charges,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,10,,,percent of total billed charges,,,10,,,percent of total billed charges,,,,,,,,,9.3,,,percent of total billed charges,,,,,,,,,,,,,,,9.3,,,percent of total billed charges,,,9.3,,,percent of total billed charges,,,9.3,,,percent of total billed charges,,,7.5,,,percent of total billed charges,,,10,,,percent of total billed charges,,,10,,,percent of total billed charges,,,10,,,percent of total billed charges,,,,,,,,,7.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.89,,,percent of total billed charges,,
NITROGLYCERIN 2  OINT 1 GM PKT,2500014488,CDM,637,RC,281032608,NDC,999,EAPG,,,,outpatient,facility,1,UN,10,10,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROGLYCERIN/D5W 50MG/250ML,2500014497,CDM,250,RC,J3490,HCPCS,338104902,NDC,,,,inpatient,facility,250,UN,74.38,74.38,5.95,74.38,,,,,,,,,,,,,,74.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.38,,,percent of total billed charges,,,,,,,,,74.38,,,percent of total billed charges,,,37.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.63,,,percent of total billed charges,,,,,,,,,,,,,,,74.38,,,percent of total billed charges,,,63.22,,,percent of total billed charges,,,,,,,,,,,,,,,74.38,,,percent of total billed charges,,,39.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,74.38,,,percent of total billed charges,,,,,,,,,,,,,,,5.95,,,percent of total billed charges,,,74.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.82,,,percent of total billed charges,,
NITROGLYCERIN/D5W 50MG/250ML,2500014497,CDM,250,RC,J3490,HCPCS,338104902,NDC,,,,outpatient,facility,250,UN,74.38,74.38,1.2,548.68,,52.74,,,percent of total billed charges,,,18.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,74.38,,,percent of total billed charges,,,46.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,52.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,52.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,74.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,27.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,74.38,,,fee schedule,,,74.38,,,percent of total billed charges,,,,,,,,,74.38,,,percent of total billed charges,,,45.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53,,,percent of total billed charges,,,,,,,,,,,,,,,74.38,,,percent of total billed charges,,,74.38,,,percent of total billed charges,,,74.38,,,percent of total billed charges,,,,,,,,,43.88,,,percent of total billed charges,,,548.68,,,per diem,,,74.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,74.38,,,percent of total billed charges,,,63.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.5,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.18,,,percent of total billed charges,,,60.19,,,percent of total billed charges,,,,,,,,,,,,,,,29.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,74.38,,,percent of total billed charges,,,74.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,74.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.95,,,percent of total billed charges,,,74.38,,,percent of total billed charges,,,,,,,,,,,,,,,74.38,,,percent of total billed charges,,,74.38,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,55.78,,,percent of total billed charges,,,74.38,,,percent of total billed charges,,,74.38,,,percent of total billed charges,,,74.38,,,percent of total billed charges,,,,,,,,,52.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,43.82,,,percent of total billed charges,,
NITROGLYCERIN/D5W 50MG/250ML,2500014497,CDM,250,RC,J3490,HCPCS,338104902,NDC,435,EAPG,,outpatient,facility,250,UN,74.38,74.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROPRUSSIDE SOD 50MG/2ML INJ,2500014500,CDM,250,RC,J3490,HCPCS,1478901202,NDC,,,,inpatient,facility,2,UN,264,264,21.12,264,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,264,,,percent of total billed charges,,,134.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,140.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,21.12,,,percent of total billed charges,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.55,,,percent of total billed charges,,
NITROPRUSSIDE SOD 50MG/2ML INJ,2500014500,CDM,250,RC,J3490,HCPCS,1478901202,NDC,,,,outpatient,facility,2,UN,264,264,1.2,548.68,,187.2,,,percent of total billed charges,,,64.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,264,,,percent of total billed charges,,,165.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,185.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,185.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,96.62,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,264,,,fee schedule,,,264,,,percent of total billed charges,,,,,,,,,264,,,percent of total billed charges,,,161.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.1,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,264,,,percent of total billed charges,,,264,,,percent of total billed charges,,,,,,,,,155.76,,,percent of total billed charges,,,548.68,,,per diem,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,264,,,percent of total billed charges,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.21,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.09,,,percent of total billed charges,,,213.63,,,percent of total billed charges,,,,,,,,,,,,,,,105.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,264,,,percent of total billed charges,,,264,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,264,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.12,,,percent of total billed charges,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,264,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,198,,,percent of total billed charges,,,264,,,percent of total billed charges,,,264,,,percent of total billed charges,,,264,,,percent of total billed charges,,,,,,,,,185.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,155.55,,,percent of total billed charges,,
NITROPRUSSIDE SOD 50MG/2ML INJ,2500014500,CDM,250,RC,J3490,HCPCS,1478901202,NDC,435,EAPG,,outpatient,facility,2,UN,264,264,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROPRUSSIDE 50MG/250ML VIAL,2500014502,CDM,636,RC,J3490,HCPCS,1478901202,NDC,,,,inpatient,facility,250,UN,1089,1089,87.12,1089,,,,,,,,,,,,,,1089,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1089,,,percent of total billed charges,,,,,,,,,1089,,,percent of total billed charges,,,556.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,927.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,653.4,,,percent of total billed charges,,,,,,,,,,,,,,,1089,,,percent of total billed charges,,,925.65,,,percent of total billed charges,,,,,,,,,,,,,,,1089,,,percent of total billed charges,,,578.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,435.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1089,,,percent of total billed charges,,,,,,,,,,,,,,,87.12,,,percent of total billed charges,,,1089,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1089,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.64,,,percent of total billed charges,,
NITROPRUSSIDE 50MG/250ML VIAL,2500014502,CDM,636,RC,J3490,HCPCS,1478901202,NDC,,,,outpatient,facility,250,UN,1089,1089,1.2,1089,,772.21,,,percent of total billed charges,,,265.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1089,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1089,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,398.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,1089,,,fee schedule,,,1089,,,percent of total billed charges,,,,,,,,,1089,,,percent of total billed charges,,,667.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,775.91,,,percent of total billed charges,,,,,,,,,,,,,,,1089,,,percent of total billed charges,,,1089,,,percent of total billed charges,,,1089,,,percent of total billed charges,,,,,,,,,642.51,,,percent of total billed charges,,,548.68,,,per diem,,,1089,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1089,,,percent of total billed charges,,,925.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,578.37,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,734.64,,,percent of total billed charges,,,881.22,,,percent of total billed charges,,,,,,,,,,,,,,,435.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1089,,,percent of total billed charges,,,1089,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1089,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,87.12,,,percent of total billed charges,,,1089,,,percent of total billed charges,,,,,,,,,,,,,,,1089,,,percent of total billed charges,,,1089,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,816.75,,,percent of total billed charges,,,1089,,,percent of total billed charges,,,1089,,,percent of total billed charges,,,1089,,,percent of total billed charges,,,,,,,,,763.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,544.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,641.64,,,percent of total billed charges,,
NITROPRUSSIDE 50MG/250ML VIAL,2500014502,CDM,636,RC,J3490,HCPCS,1478901202,NDC,435,EAPG,,outpatient,facility,250,UN,1089,1089,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NON-FORMULARY MEDICATION,2500014530,CDM,637,RC,,,,,,,,inpatient,facility,1,UN,117399.08,117399.08,9391.93,117399.08,,,,,,,,,,,,,,117399.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117399.08,,,percent of total billed charges,,,,,,,,,117399.08,,,percent of total billed charges,,,59943.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99988.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70439.45,,,percent of total billed charges,,,,,,,,,,,,,,,117399.08,,,percent of total billed charges,,,99789.22,,,percent of total billed charges,,,,,,,,,,,,,,,117399.08,,,percent of total billed charges,,,62350.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46959.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,117399.08,,,percent of total billed charges,,,,,,,,,,,,,,,9391.93,,,percent of total billed charges,,,117399.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,117399.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69171.54,,,percent of total billed charges,,
NON-FORMULARY MEDICATION,2500014530,CDM,637,RC,,,,,,,,outpatient,facility,1,UN,117399.08,117399.08,357.82,117399.08,,83247.69,,,percent of total billed charges,,,28645.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,117399.08,,,percent of total billed charges,,,73574,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,82531.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,82531.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,117399.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,42968.06,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,117399.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,117399.08,,,fee schedule,,,117399.08,,,percent of total billed charges,,,,,,,,,117399.08,,,percent of total billed charges,,,71953.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83646.84,,,percent of total billed charges,,,,,,,,,,,,,,,63395.5,,,percent of total billed charges,,,61047.52,,,percent of total billed charges,,,64569.49,,,percent of total billed charges,,,,,,,,,69265.46,,,percent of total billed charges,,,548.68,,,per diem,,,117399.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,117399.08,,,percent of total billed charges,,,99789.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62350.65,,,percent of total billed charges,,,117399.08,,,percent of total billed charges,,,117399.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79197.42,,,percent of total billed charges,,,94999.34,,,percent of total billed charges,,,,,,,,,,,,,,,46959.63,,,percent of total billed charges,,,,,,,,,43437.66,,,percent of total billed charges,,,43437.66,,,percent of total billed charges,,,,,,,,,117399.08,,,percent of total billed charges,,,117399.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,117399.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9391.93,,,percent of total billed charges,,,117399.08,,,percent of total billed charges,,,,,,,,,,,,,,,117399.08,,,percent of total billed charges,,,117399.08,,,percent of total billed charges,,,,,,,,,109204.62,,,percent of total billed charges,,,,,,,,,,,,,,,109204.62,,,percent of total billed charges,,,109204.62,,,percent of total billed charges,,,109204.62,,,percent of total billed charges,,,88049.31,,,percent of total billed charges,,,117399.08,,,percent of total billed charges,,,117399.08,,,percent of total billed charges,,,117399.08,,,percent of total billed charges,,,,,,,,,82308.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58699.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,69171.54,,,percent of total billed charges,,
NON-FORMULARY MEDICATION,2500014530,CDM,637,RC,999,EAPG,,,,,,outpatient,facility,1,UN,117399.08,117399.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NOREPINEPHRINE 1MG/ML 4 ML INJ,2500014540,CDM,250,RC,409337504,NDC,,,,,,inpatient,facility,4,UN,74.18,74.18,5.93,74.18,,,,,,,,,,,,,,74.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.18,,,percent of total billed charges,,,,,,,,,74.18,,,percent of total billed charges,,,37.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.51,,,percent of total billed charges,,,,,,,,,,,,,,,74.18,,,percent of total billed charges,,,63.05,,,percent of total billed charges,,,,,,,,,,,,,,,74.18,,,percent of total billed charges,,,39.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,74.18,,,percent of total billed charges,,,,,,,,,,,,,,,5.93,,,percent of total billed charges,,,74.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.71,,,percent of total billed charges,,
NOREPINEPHRINE 1MG/ML 4 ML INJ,2500014540,CDM,250,RC,409337504,NDC,,,,,,outpatient,facility,4,UN,74.18,74.18,5.93,548.68,,52.6,,,percent of total billed charges,,,18.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,74.18,,,percent of total billed charges,,,46.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,52.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,52.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,74.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,27.15,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,74.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,74.18,,,fee schedule,,,74.18,,,percent of total billed charges,,,,,,,,,74.18,,,percent of total billed charges,,,45.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,43.77,,,percent of total billed charges,,,548.68,,,per diem,,,74.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,74.18,,,percent of total billed charges,,,63.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.4,,,percent of total billed charges,,,74.18,,,percent of total billed charges,,,74.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.04,,,percent of total billed charges,,,60.03,,,percent of total billed charges,,,,,,,,,,,,,,,29.67,,,percent of total billed charges,,,,,,,,,29.67,,,percent of total billed charges,,,29.67,,,percent of total billed charges,,,,,,,,,74.18,,,percent of total billed charges,,,74.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,74.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.93,,,percent of total billed charges,,,74.18,,,percent of total billed charges,,,,,,,,,,,,,,,74.18,,,percent of total billed charges,,,74.18,,,percent of total billed charges,,,,,,,,,29.67,,,percent of total billed charges,,,,,,,,,,,,,,,29.67,,,percent of total billed charges,,,29.67,,,percent of total billed charges,,,29.67,,,percent of total billed charges,,,55.64,,,percent of total billed charges,,,74.18,,,percent of total billed charges,,,74.18,,,percent of total billed charges,,,74.18,,,percent of total billed charges,,,,,,,,,52.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,43.71,,,percent of total billed charges,,
NOREPINEPHRINE 1MG/ML 4 ML INJ,2500014540,CDM,250,RC,409337504,NDC,999,EAPG,,,,outpatient,facility,4,UN,74.18,74.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NOREPINEPHRINE 8 MG NS 250ML,2500014547,CDM,250,RC,,,,,,,,inpatient,facility,250,UN,127.61,127.61,10.21,127.61,,,,,,,,,,,,,,127.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.61,,,percent of total billed charges,,,,,,,,,127.61,,,percent of total billed charges,,,65.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.57,,,percent of total billed charges,,,,,,,,,,,,,,,127.61,,,percent of total billed charges,,,108.47,,,percent of total billed charges,,,,,,,,,,,,,,,127.61,,,percent of total billed charges,,,67.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,127.61,,,percent of total billed charges,,,,,,,,,,,,,,,10.21,,,percent of total billed charges,,,127.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,127.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.19,,,percent of total billed charges,,
NOREPINEPHRINE 8 MG NS 250ML,2500014547,CDM,250,RC,,,,,,,,outpatient,facility,250,UN,127.61,127.61,10.21,548.68,,90.49,,,percent of total billed charges,,,31.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,127.61,,,percent of total billed charges,,,79.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,89.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,89.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,127.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,46.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,127.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,127.61,,,fee schedule,,,127.61,,,percent of total billed charges,,,,,,,,,127.61,,,percent of total billed charges,,,78.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,75.29,,,percent of total billed charges,,,548.68,,,per diem,,,127.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,127.61,,,percent of total billed charges,,,108.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.77,,,percent of total billed charges,,,127.61,,,percent of total billed charges,,,127.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.09,,,percent of total billed charges,,,103.26,,,percent of total billed charges,,,,,,,,,,,,,,,51.04,,,percent of total billed charges,,,,,,,,,51.04,,,percent of total billed charges,,,51.04,,,percent of total billed charges,,,,,,,,,127.61,,,percent of total billed charges,,,127.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,127.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.21,,,percent of total billed charges,,,127.61,,,percent of total billed charges,,,,,,,,,,,,,,,127.61,,,percent of total billed charges,,,127.61,,,percent of total billed charges,,,,,,,,,51.04,,,percent of total billed charges,,,,,,,,,,,,,,,51.04,,,percent of total billed charges,,,51.04,,,percent of total billed charges,,,51.04,,,percent of total billed charges,,,95.71,,,percent of total billed charges,,,127.61,,,percent of total billed charges,,,127.61,,,percent of total billed charges,,,127.61,,,percent of total billed charges,,,,,,,,,89.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,75.19,,,percent of total billed charges,,
NOREPINEPHRINE 8 MG NS 250ML,2500014547,CDM,250,RC,999,EAPG,,,,,,outpatient,facility,250,UN,127.61,127.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NORTRIPTYLINE HCL 10 MG CAP,2500014570,CDM,637,RC,5167240011,NDC,,,,,,inpatient,facility,10,UN,2.41,2.41,0.19,2.41,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,2.41,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,
NORTRIPTYLINE HCL 10 MG CAP,2500014570,CDM,637,RC,5167240011,NDC,,,,,,outpatient,facility,10,UN,2.41,2.41,0.19,548.68,,1.71,,,percent of total billed charges,,,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.41,,,percent of total billed charges,,,1.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.88,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.41,,,fee schedule,,,2.41,,,percent of total billed charges,,,,,,,,,2.41,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,1.42,,,percent of total billed charges,,,548.68,,,per diem,,,2.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.41,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,,,,,,,0.89,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,2.41,,,percent of total billed charges,,,2.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.19,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,,,,,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,2.41,,,percent of total billed charges,,,,,,,,,1.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.42,,,percent of total billed charges,,
NORTRIPTYLINE HCL 10 MG CAP,2500014570,CDM,637,RC,5167240011,NDC,999,EAPG,,,,outpatient,facility,10,UN,2.41,2.41,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NORTRIPTYLINE HCL 25 MG CAP,2500014572,CDM,637,RC,6068729301,NDC,,,,,,inpatient,facility,25,UN,2.9,2.9,0.23,2.9,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,2.9,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,
NORTRIPTYLINE HCL 25 MG CAP,2500014572,CDM,637,RC,6068729301,NDC,,,,,,outpatient,facility,25,UN,2.9,2.9,0.23,548.68,,2.06,,,percent of total billed charges,,,0.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.9,,,percent of total billed charges,,,1.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.06,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.9,,,fee schedule,,,2.9,,,percent of total billed charges,,,,,,,,,2.9,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,1.71,,,percent of total billed charges,,,548.68,,,per diem,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.9,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,1.07,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,2.9,,,percent of total billed charges,,,2.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.71,,,percent of total billed charges,,
NORTRIPTYLINE HCL 25 MG CAP,2500014572,CDM,637,RC,6068729301,NDC,999,EAPG,,,,outpatient,facility,25,UN,2.9,2.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NYSTATIN 100000 U/GM CR 15GM,2500014590,CDM,637,RC,4580205935,NDC,,,,,,inpatient,facility,15,UN,46.2,46.2,3.7,46.2,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,23.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.72,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,39.27,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,24.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.22,,,percent of total billed charges,,
NYSTATIN 100000 U/GM CR 15GM,2500014590,CDM,637,RC,4580205935,NDC,,,,,,outpatient,facility,15,UN,46.2,46.2,3.7,548.68,,32.76,,,percent of total billed charges,,,11.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,46.2,,,percent of total billed charges,,,28.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,32.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,32.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,16.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,46.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,46.2,,,fee schedule,,,46.2,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,28.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.92,,,percent of total billed charges,,,,,,,,,,,,,,,24.95,,,percent of total billed charges,,,24.02,,,percent of total billed charges,,,25.41,,,percent of total billed charges,,,,,,,,,27.26,,,percent of total billed charges,,,548.68,,,per diem,,,46.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,46.2,,,percent of total billed charges,,,39.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.54,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.17,,,percent of total billed charges,,,37.39,,,percent of total billed charges,,,,,,,,,,,,,,,18.48,,,percent of total billed charges,,,,,,,,,17.09,,,percent of total billed charges,,,17.09,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,42.98,,,percent of total billed charges,,,,,,,,,,,,,,,42.98,,,percent of total billed charges,,,42.98,,,percent of total billed charges,,,42.98,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,32.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,27.22,,,percent of total billed charges,,
NYSTATIN 100000 U/GM CR 15GM,2500014590,CDM,637,RC,4580205935,NDC,999,EAPG,,,,outpatient,facility,15,UN,46.2,46.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NYSTATIN 100000 U/GM OINT 15G,2500014591,CDM,637,RC,713068615,NDC,,,,,,inpatient,facility,15,UN,57.75,57.75,4.62,57.75,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,,,,,,,57.75,,,percent of total billed charges,,,29.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,49.09,,,percent of total billed charges,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,30.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.03,,,percent of total billed charges,,
NYSTATIN 100000 U/GM OINT 15G,2500014591,CDM,637,RC,713068615,NDC,,,,,,outpatient,facility,15,UN,57.75,57.75,4.62,548.68,,40.95,,,percent of total billed charges,,,14.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,57.75,,,percent of total billed charges,,,36.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,40.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,40.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,21.14,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,57.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,57.75,,,fee schedule,,,57.75,,,percent of total billed charges,,,,,,,,,57.75,,,percent of total billed charges,,,35.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.15,,,percent of total billed charges,,,,,,,,,,,,,,,31.19,,,percent of total billed charges,,,30.03,,,percent of total billed charges,,,31.76,,,percent of total billed charges,,,,,,,,,34.07,,,percent of total billed charges,,,548.68,,,per diem,,,57.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,57.75,,,percent of total billed charges,,,49.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.67,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.96,,,percent of total billed charges,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,23.1,,,percent of total billed charges,,,,,,,,,21.37,,,percent of total billed charges,,,21.37,,,percent of total billed charges,,,,,,,,,57.75,,,percent of total billed charges,,,57.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,57.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.62,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,,,,,,,,,,,,,57.75,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,,,,,,,53.72,,,percent of total billed charges,,,,,,,,,,,,,,,53.72,,,percent of total billed charges,,,53.72,,,percent of total billed charges,,,53.72,,,percent of total billed charges,,,43.31,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,57.75,,,percent of total billed charges,,,,,,,,,40.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,34.03,,,percent of total billed charges,,
NYSTATIN 100000 U/GM OINT 15G,2500014591,CDM,637,RC,713068615,NDC,999,EAPG,,,,outpatient,facility,15,UN,57.75,57.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NYSTATIN 100000 U/ML SUSP 5ML,2500014593,CDM,637,RC,121086800,NDC,,,,,,inpatient,facility,5,UN,7.49,7.49,0.6,7.49,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,7.49,,,percent of total billed charges,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.49,,,percent of total billed charges,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,6.37,,,percent of total billed charges,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.41,,,percent of total billed charges,,
NYSTATIN 100000 U/ML SUSP 5ML,2500014593,CDM,637,RC,121086800,NDC,,,,,,outpatient,facility,5,UN,7.49,7.49,0.6,548.68,,5.31,,,percent of total billed charges,,,1.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.49,,,percent of total billed charges,,,4.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.49,,,fee schedule,,,7.49,,,percent of total billed charges,,,,,,,,,7.49,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.34,,,percent of total billed charges,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,548.68,,,per diem,,,7.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.49,,,percent of total billed charges,,,6.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.98,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.05,,,percent of total billed charges,,,6.06,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,7.49,,,percent of total billed charges,,,7.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.6,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,6.97,,,percent of total billed charges,,,,,,,,,,,,,,,6.97,,,percent of total billed charges,,,6.97,,,percent of total billed charges,,,6.97,,,percent of total billed charges,,,5.62,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,,,,,,,5.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.41,,,percent of total billed charges,,
NYSTATIN 100000 U/ML SUSP 5ML,2500014593,CDM,637,RC,121086800,NDC,999,EAPG,,,,outpatient,facility,5,UN,7.49,7.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NYSTATIN/TRIAMCINOL CRM 15 GM,2500014600,CDM,637,RC,4580288014,NDC,,,,,,inpatient,facility,15,UN,69.14,69.14,5.53,69.14,,,,,,,,,,,,,,69.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.14,,,percent of total billed charges,,,,,,,,,69.14,,,percent of total billed charges,,,35.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.48,,,percent of total billed charges,,,,,,,,,,,,,,,69.14,,,percent of total billed charges,,,58.77,,,percent of total billed charges,,,,,,,,,,,,,,,69.14,,,percent of total billed charges,,,36.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,69.14,,,percent of total billed charges,,,,,,,,,,,,,,,5.53,,,percent of total billed charges,,,69.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.74,,,percent of total billed charges,,
NYSTATIN/TRIAMCINOL CRM 15 GM,2500014600,CDM,637,RC,4580288014,NDC,,,,,,outpatient,facility,15,UN,69.14,69.14,5.53,548.68,,49.03,,,percent of total billed charges,,,16.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,69.14,,,percent of total billed charges,,,43.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,48.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,48.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,69.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,25.31,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,69.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,69.14,,,fee schedule,,,69.14,,,percent of total billed charges,,,,,,,,,69.14,,,percent of total billed charges,,,42.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.26,,,percent of total billed charges,,,,,,,,,,,,,,,37.34,,,percent of total billed charges,,,35.95,,,percent of total billed charges,,,38.03,,,percent of total billed charges,,,,,,,,,40.79,,,percent of total billed charges,,,548.68,,,per diem,,,69.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,69.14,,,percent of total billed charges,,,58.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.72,,,percent of total billed charges,,,69.14,,,percent of total billed charges,,,69.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.64,,,percent of total billed charges,,,55.95,,,percent of total billed charges,,,,,,,,,,,,,,,27.66,,,percent of total billed charges,,,,,,,,,25.58,,,percent of total billed charges,,,25.58,,,percent of total billed charges,,,,,,,,,69.14,,,percent of total billed charges,,,69.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,69.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.53,,,percent of total billed charges,,,69.14,,,percent of total billed charges,,,,,,,,,,,,,,,69.14,,,percent of total billed charges,,,69.14,,,percent of total billed charges,,,,,,,,,64.31,,,percent of total billed charges,,,,,,,,,,,,,,,64.31,,,percent of total billed charges,,,64.31,,,percent of total billed charges,,,64.31,,,percent of total billed charges,,,51.86,,,percent of total billed charges,,,69.14,,,percent of total billed charges,,,69.14,,,percent of total billed charges,,,69.14,,,percent of total billed charges,,,,,,,,,48.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,40.74,,,percent of total billed charges,,
NYSTATIN/TRIAMCINOL CRM 15 GM,2500014600,CDM,637,RC,4580288014,NDC,999,EAPG,,,,outpatient,facility,15,UN,69.14,69.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OFLOXACIN 0.3  OPH 5 ML,2500014610,CDM,637,RC,6498051505,NDC,,,,,,inpatient,facility,5,UN,25.54,25.54,2.04,25.54,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,25.54,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.32,,,percent of total billed charges,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,21.71,,,percent of total billed charges,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,13.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.05,,,percent of total billed charges,,
OFLOXACIN 0.3  OPH 5 ML,2500014610,CDM,637,RC,6498051505,NDC,,,,,,outpatient,facility,5,UN,25.54,25.54,2.04,548.68,,18.11,,,percent of total billed charges,,,6.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,25.54,,,percent of total billed charges,,,16.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,17.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,17.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.35,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,25.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,25.54,,,fee schedule,,,25.54,,,percent of total billed charges,,,,,,,,,25.54,,,percent of total billed charges,,,15.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.79,,,percent of total billed charges,,,13.28,,,percent of total billed charges,,,14.05,,,percent of total billed charges,,,,,,,,,15.07,,,percent of total billed charges,,,548.68,,,per diem,,,25.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,25.54,,,percent of total billed charges,,,21.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.56,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.23,,,percent of total billed charges,,,20.67,,,percent of total billed charges,,,,,,,,,,,,,,,10.22,,,percent of total billed charges,,,,,,,,,9.45,,,percent of total billed charges,,,9.45,,,percent of total billed charges,,,,,,,,,25.54,,,percent of total billed charges,,,25.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.04,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,19.16,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,17.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15.05,,,percent of total billed charges,,
OFLOXACIN 0.3  OPH 5 ML,2500014610,CDM,637,RC,6498051505,NDC,999,EAPG,,,,outpatient,facility,5,UN,25.54,25.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OFLOXACIN 0.3 OTIC 10 ML,2500014616,CDM,637,RC,6050503632,NDC,,,,,,inpatient,facility,10,UN,1018.25,1018.25,81.46,1018.25,,,,,,,,,,,,,,1018.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1018.25,,,percent of total billed charges,,,,,,,,,1018.25,,,percent of total billed charges,,,519.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,867.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,610.95,,,percent of total billed charges,,,,,,,,,,,,,,,1018.25,,,percent of total billed charges,,,865.51,,,percent of total billed charges,,,,,,,,,,,,,,,1018.25,,,percent of total billed charges,,,540.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1018.25,,,percent of total billed charges,,,,,,,,,,,,,,,81.46,,,percent of total billed charges,,,1018.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1018.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.95,,,percent of total billed charges,,
OFLOXACIN 0.3 OTIC 10 ML,2500014616,CDM,637,RC,6050503632,NDC,,,,,,outpatient,facility,10,UN,1018.25,1018.25,81.46,1018.25,,722.04,,,percent of total billed charges,,,248.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1018.25,,,percent of total billed charges,,,638.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,715.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,715.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1018.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,372.68,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1018.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1018.25,,,fee schedule,,,1018.25,,,percent of total billed charges,,,,,,,,,1018.25,,,percent of total billed charges,,,624.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,725.5,,,percent of total billed charges,,,,,,,,,,,,,,,549.86,,,percent of total billed charges,,,529.49,,,percent of total billed charges,,,560.04,,,percent of total billed charges,,,,,,,,,600.77,,,percent of total billed charges,,,548.68,,,per diem,,,1018.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1018.25,,,percent of total billed charges,,,865.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,540.79,,,percent of total billed charges,,,1018.25,,,percent of total billed charges,,,1018.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,686.91,,,percent of total billed charges,,,823.97,,,percent of total billed charges,,,,,,,,,,,,,,,407.3,,,percent of total billed charges,,,,,,,,,376.75,,,percent of total billed charges,,,376.75,,,percent of total billed charges,,,,,,,,,1018.25,,,percent of total billed charges,,,1018.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1018.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,81.46,,,percent of total billed charges,,,1018.25,,,percent of total billed charges,,,,,,,,,,,,,,,1018.25,,,percent of total billed charges,,,1018.25,,,percent of total billed charges,,,,,,,,,947.18,,,percent of total billed charges,,,,,,,,,,,,,,,947.18,,,percent of total billed charges,,,947.18,,,percent of total billed charges,,,947.18,,,percent of total billed charges,,,763.69,,,percent of total billed charges,,,1018.25,,,percent of total billed charges,,,1018.25,,,percent of total billed charges,,,1018.25,,,percent of total billed charges,,,,,,,,,713.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,509.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,599.95,,,percent of total billed charges,,
OFLOXACIN 0.3 OTIC 10 ML,2500014616,CDM,637,RC,6050503632,NDC,999,EAPG,,,,outpatient,facility,10,UN,1018.25,1018.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OLANZAPINE 10 MG DIS TAB,2500014620,CDM,637,RC,3334208407,NDC,,,,,,inpatient,facility,10,UN,68.21,68.21,5.46,68.21,,,,,,,,,,,,,,68.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.21,,,percent of total billed charges,,,,,,,,,68.21,,,percent of total billed charges,,,34.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.93,,,percent of total billed charges,,,,,,,,,,,,,,,68.21,,,percent of total billed charges,,,57.98,,,percent of total billed charges,,,,,,,,,,,,,,,68.21,,,percent of total billed charges,,,36.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,68.21,,,percent of total billed charges,,,,,,,,,,,,,,,5.46,,,percent of total billed charges,,,68.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,
OLANZAPINE 10 MG DIS TAB,2500014620,CDM,637,RC,3334208407,NDC,,,,,,outpatient,facility,10,UN,68.21,68.21,5.46,548.68,,48.37,,,percent of total billed charges,,,16.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,68.21,,,percent of total billed charges,,,42.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,47.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,47.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,68.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,24.96,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,68.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,68.21,,,fee schedule,,,68.21,,,percent of total billed charges,,,,,,,,,68.21,,,percent of total billed charges,,,41.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.6,,,percent of total billed charges,,,,,,,,,,,,,,,36.83,,,percent of total billed charges,,,35.47,,,percent of total billed charges,,,37.52,,,percent of total billed charges,,,,,,,,,40.24,,,percent of total billed charges,,,548.68,,,per diem,,,68.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,68.21,,,percent of total billed charges,,,57.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.23,,,percent of total billed charges,,,68.21,,,percent of total billed charges,,,68.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.01,,,percent of total billed charges,,,55.2,,,percent of total billed charges,,,,,,,,,,,,,,,27.28,,,percent of total billed charges,,,,,,,,,25.24,,,percent of total billed charges,,,25.24,,,percent of total billed charges,,,,,,,,,68.21,,,percent of total billed charges,,,68.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,68.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.46,,,percent of total billed charges,,,68.21,,,percent of total billed charges,,,,,,,,,,,,,,,68.21,,,percent of total billed charges,,,68.21,,,percent of total billed charges,,,,,,,,,63.45,,,percent of total billed charges,,,,,,,,,,,,,,,63.45,,,percent of total billed charges,,,63.45,,,percent of total billed charges,,,63.45,,,percent of total billed charges,,,51.16,,,percent of total billed charges,,,68.21,,,percent of total billed charges,,,68.21,,,percent of total billed charges,,,68.21,,,percent of total billed charges,,,,,,,,,47.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,40.19,,,percent of total billed charges,,
OLANZAPINE 10 MG DIS TAB,2500014620,CDM,637,RC,3334208407,NDC,999,EAPG,,,,outpatient,facility,10,UN,68.21,68.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OLANZAPINE 10 MG TAB,2500014621,CDM,637,RC,904637661,NDC,,,,,,inpatient,facility,10,UN,1.58,1.58,0.13,1.58,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,1.58,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,
OLANZAPINE 10 MG TAB,2500014621,CDM,637,RC,904637661,NDC,,,,,,outpatient,facility,10,UN,1.58,1.58,0.13,548.68,,1.12,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.58,,,percent of total billed charges,,,0.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.58,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.58,,,fee schedule,,,1.58,,,percent of total billed charges,,,,,,,,,1.58,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,0.93,,,percent of total billed charges,,,548.68,,,per diem,,,1.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.58,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,,,,,,,1.58,,,percent of total billed charges,,,1.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.93,,,percent of total billed charges,,
OLANZAPINE 10 MG TAB,2500014621,CDM,637,RC,904637661,NDC,999,EAPG,,,,outpatient,facility,10,UN,1.58,1.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OLANZAPINE 2.5 MG TAB,2500014622,CDM,637,RC,904628361,NDC,,,,,,inpatient,facility,2.5,UN,1.15,1.15,0.09,1.15,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,1.15,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,
OLANZAPINE 2.5 MG TAB,2500014622,CDM,637,RC,904628361,NDC,,,,,,outpatient,facility,2.5,UN,1.15,1.15,0.09,548.68,,0.82,,,percent of total billed charges,,,0.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.15,,,percent of total billed charges,,,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.42,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.15,,,fee schedule,,,1.15,,,percent of total billed charges,,,,,,,,,1.15,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,0.68,,,percent of total billed charges,,,548.68,,,per diem,,,1.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.15,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,1.15,,,percent of total billed charges,,,1.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.68,,,percent of total billed charges,,
OLANZAPINE 2.5 MG TAB,2500014622,CDM,637,RC,904628361,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,1.15,1.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OLANZAPINE 5 MG DIS TAB,2500014623,CDM,637,RC,3334208307,NDC,,,,,,inpatient,facility,5,UN,46.2,46.2,3.7,46.2,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,23.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.72,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,39.27,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,24.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.22,,,percent of total billed charges,,
OLANZAPINE 5 MG DIS TAB,2500014623,CDM,637,RC,3334208307,NDC,,,,,,outpatient,facility,5,UN,46.2,46.2,3.7,548.68,,32.76,,,percent of total billed charges,,,11.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,46.2,,,percent of total billed charges,,,28.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,32.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,32.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,16.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,46.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,46.2,,,fee schedule,,,46.2,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,28.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.92,,,percent of total billed charges,,,,,,,,,,,,,,,24.95,,,percent of total billed charges,,,24.02,,,percent of total billed charges,,,25.41,,,percent of total billed charges,,,,,,,,,27.26,,,percent of total billed charges,,,548.68,,,per diem,,,46.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,46.2,,,percent of total billed charges,,,39.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.54,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.17,,,percent of total billed charges,,,37.39,,,percent of total billed charges,,,,,,,,,,,,,,,18.48,,,percent of total billed charges,,,,,,,,,17.09,,,percent of total billed charges,,,17.09,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,42.98,,,percent of total billed charges,,,,,,,,,,,,,,,42.98,,,percent of total billed charges,,,42.98,,,percent of total billed charges,,,42.98,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,32.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,27.22,,,percent of total billed charges,,
OLANZAPINE 5 MG DIS TAB,2500014623,CDM,637,RC,3334208307,NDC,999,EAPG,,,,outpatient,facility,5,UN,46.2,46.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OLANZAPINE 5 MG TAB,2500014624,CDM,637,RC,904637761,NDC,,,,,,inpatient,facility,5,UN,1.18,1.18,0.09,1.18,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,
OLANZAPINE 5 MG TAB,2500014624,CDM,637,RC,904637761,NDC,,,,,,outpatient,facility,5,UN,1.18,1.18,0.09,548.68,,0.84,,,percent of total billed charges,,,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.18,,,percent of total billed charges,,,0.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.43,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.18,,,fee schedule,,,1.18,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,0.7,,,percent of total billed charges,,,548.68,,,per diem,,,1.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.18,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,0.44,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,1.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.7,,,percent of total billed charges,,
OLANZAPINE 5 MG TAB,2500014624,CDM,637,RC,904637761,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.18,1.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OLANZAPINE 10 MG INJ,2500014629,CDM,250,RC,J3490,HCPCS,781315972,NDC,,,,inpatient,facility,10,UN,136.95,136.95,10.96,136.95,,,,,,,,,,,,,,136.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.95,,,percent of total billed charges,,,,,,,,,136.95,,,percent of total billed charges,,,69.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.17,,,percent of total billed charges,,,,,,,,,,,,,,,136.95,,,percent of total billed charges,,,116.41,,,percent of total billed charges,,,,,,,,,,,,,,,136.95,,,percent of total billed charges,,,72.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,136.95,,,percent of total billed charges,,,,,,,,,,,,,,,10.96,,,percent of total billed charges,,,136.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,136.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.69,,,percent of total billed charges,,
OLANZAPINE 10 MG INJ,2500014629,CDM,250,RC,J3490,HCPCS,781315972,NDC,,,,outpatient,facility,10,UN,136.95,136.95,1.2,548.68,,97.11,,,percent of total billed charges,,,33.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,136.95,,,percent of total billed charges,,,85.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,96.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,96.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,136.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,50.12,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,136.95,,,fee schedule,,,136.95,,,percent of total billed charges,,,,,,,,,136.95,,,percent of total billed charges,,,83.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.58,,,percent of total billed charges,,,,,,,,,,,,,,,136.95,,,percent of total billed charges,,,136.95,,,percent of total billed charges,,,136.95,,,percent of total billed charges,,,,,,,,,80.8,,,percent of total billed charges,,,548.68,,,per diem,,,136.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,136.95,,,percent of total billed charges,,,116.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.73,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.39,,,percent of total billed charges,,,110.82,,,percent of total billed charges,,,,,,,,,,,,,,,54.78,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,136.95,,,percent of total billed charges,,,136.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,136.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.96,,,percent of total billed charges,,,136.95,,,percent of total billed charges,,,,,,,,,,,,,,,136.95,,,percent of total billed charges,,,136.95,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,102.71,,,percent of total billed charges,,,136.95,,,percent of total billed charges,,,136.95,,,percent of total billed charges,,,136.95,,,percent of total billed charges,,,,,,,,,96.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,80.69,,,percent of total billed charges,,
OLANZAPINE 10 MG INJ,2500014629,CDM,250,RC,J3490,HCPCS,781315972,NDC,435,EAPG,,outpatient,facility,10,UN,136.95,136.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OMEPRAZOLE 20 MG CAPCR,2500014642,CDM,637,RC,6838241201,NDC,,,,,,inpatient,facility,20,UN,13.7,13.7,1.1,13.7,,,,,,,,,,,,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.7,,,percent of total billed charges,,,,,,,,,13.7,,,percent of total billed charges,,,7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.22,,,percent of total billed charges,,,,,,,,,,,,,,,13.7,,,percent of total billed charges,,,11.64,,,percent of total billed charges,,,,,,,,,,,,,,,13.7,,,percent of total billed charges,,,7.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.07,,,percent of total billed charges,,
OMEPRAZOLE 20 MG CAPCR,2500014642,CDM,637,RC,6838241201,NDC,,,,,,outpatient,facility,20,UN,13.7,13.7,1.1,548.68,,9.71,,,percent of total billed charges,,,3.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.7,,,percent of total billed charges,,,8.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.7,,,fee schedule,,,13.7,,,percent of total billed charges,,,,,,,,,13.7,,,percent of total billed charges,,,8.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.76,,,percent of total billed charges,,,,,,,,,,,,,,,7.4,,,percent of total billed charges,,,7.12,,,percent of total billed charges,,,7.54,,,percent of total billed charges,,,,,,,,,8.08,,,percent of total billed charges,,,548.68,,,per diem,,,13.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.7,,,percent of total billed charges,,,11.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.28,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,11.09,,,percent of total billed charges,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,5.07,,,percent of total billed charges,,,5.07,,,percent of total billed charges,,,,,,,,,13.7,,,percent of total billed charges,,,13.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.1,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,,,,,,,,,,,,,13.7,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,,,,,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,10.27,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,13.7,,,percent of total billed charges,,,,,,,,,9.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.07,,,percent of total billed charges,,
OMEPRAZOLE 20 MG CAPCR,2500014642,CDM,637,RC,6838241201,NDC,999,EAPG,,,,outpatient,facility,20,UN,13.7,13.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OPIUM TINCT 10  10 ML,2500014651,CDM,637,RC,6255915304,NDC,,,,,,inpatient,facility,1,UN,20.69,20.69,1.66,20.69,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,,,,,,,20.69,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.41,,,percent of total billed charges,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,17.59,,,percent of total billed charges,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,10.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.19,,,percent of total billed charges,,
OPIUM TINCT 10  10 ML,2500014651,CDM,637,RC,6255915304,NDC,,,,,,outpatient,facility,1,UN,20.69,20.69,1.66,548.68,,14.67,,,percent of total billed charges,,,5.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,20.69,,,percent of total billed charges,,,12.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,14.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,14.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,20.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,20.69,,,fee schedule,,,20.69,,,percent of total billed charges,,,,,,,,,20.69,,,percent of total billed charges,,,12.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.74,,,percent of total billed charges,,,,,,,,,,,,,,,11.17,,,percent of total billed charges,,,10.76,,,percent of total billed charges,,,11.38,,,percent of total billed charges,,,,,,,,,12.21,,,percent of total billed charges,,,548.68,,,per diem,,,20.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,20.69,,,percent of total billed charges,,,17.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.99,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.96,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,,,,,,,,,,,,,8.28,,,percent of total billed charges,,,,,,,,,7.66,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,20.69,,,percent of total billed charges,,,20.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.66,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,,,,,,,,,,,,,20.69,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,,,,,,,19.25,,,percent of total billed charges,,,,,,,,,,,,,,,19.25,,,percent of total billed charges,,,19.25,,,percent of total billed charges,,,19.25,,,percent of total billed charges,,,15.52,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,20.69,,,percent of total billed charges,,,,,,,,,14.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,12.19,,,percent of total billed charges,,
OPIUM TINCT 10  10 ML,2500014651,CDM,637,RC,6255915304,NDC,999,EAPG,,,,outpatient,facility,1,UN,20.69,20.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OSELTAMIVIR 75 MG CAP,2500014690,CDM,637,RC,6818067711,NDC,,,,,,inpatient,facility,75,UN,51.02,51.02,4.08,51.02,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,51.02,,,percent of total billed charges,,,26.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.61,,,percent of total billed charges,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,43.37,,,percent of total billed charges,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,27.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,4.08,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.06,,,percent of total billed charges,,
OSELTAMIVIR 75 MG CAP,2500014690,CDM,637,RC,6818067711,NDC,,,,,,outpatient,facility,75,UN,51.02,51.02,4.08,548.68,,36.18,,,percent of total billed charges,,,12.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,51.02,,,percent of total billed charges,,,31.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,35.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,35.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,18.67,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,51.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,51.02,,,fee schedule,,,51.02,,,percent of total billed charges,,,,,,,,,51.02,,,percent of total billed charges,,,31.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.35,,,percent of total billed charges,,,,,,,,,,,,,,,27.55,,,percent of total billed charges,,,26.53,,,percent of total billed charges,,,28.06,,,percent of total billed charges,,,,,,,,,30.1,,,percent of total billed charges,,,548.68,,,per diem,,,51.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,51.02,,,percent of total billed charges,,,43.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.1,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.42,,,percent of total billed charges,,,41.29,,,percent of total billed charges,,,,,,,,,,,,,,,20.41,,,percent of total billed charges,,,,,,,,,18.88,,,percent of total billed charges,,,18.88,,,percent of total billed charges,,,,,,,,,51.02,,,percent of total billed charges,,,51.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,51.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.08,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,47.46,,,percent of total billed charges,,,,,,,,,,,,,,,47.46,,,percent of total billed charges,,,47.46,,,percent of total billed charges,,,47.46,,,percent of total billed charges,,,38.27,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,35.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,30.06,,,percent of total billed charges,,
OSELTAMIVIR 75 MG CAP,2500014690,CDM,637,RC,6818067711,NDC,999,EAPG,,,,outpatient,facility,75,UN,51.02,51.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OSELTAMIVIR 30 MG CAP,2500014691,CDM,637,RC,6818067511,NDC,,,,,,inpatient,facility,30,UN,46.79,46.79,3.74,46.79,,,,,,,,,,,,,,46.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,percent of total billed charges,,,,,,,,,46.79,,,percent of total billed charges,,,23.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.07,,,percent of total billed charges,,,,,,,,,,,,,,,46.79,,,percent of total billed charges,,,39.77,,,percent of total billed charges,,,,,,,,,,,,,,,46.79,,,percent of total billed charges,,,24.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,percent of total billed charges,,,,,,,,,,,,,,,3.74,,,percent of total billed charges,,,46.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.57,,,percent of total billed charges,,
OSELTAMIVIR 30 MG CAP,2500014691,CDM,637,RC,6818067511,NDC,,,,,,outpatient,facility,30,UN,46.79,46.79,3.74,548.68,,33.18,,,percent of total billed charges,,,11.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,46.79,,,percent of total billed charges,,,29.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,32.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,32.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,46.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,17.13,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,46.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,46.79,,,fee schedule,,,46.79,,,percent of total billed charges,,,,,,,,,46.79,,,percent of total billed charges,,,28.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.34,,,percent of total billed charges,,,,,,,,,,,,,,,25.27,,,percent of total billed charges,,,24.33,,,percent of total billed charges,,,25.73,,,percent of total billed charges,,,,,,,,,27.61,,,percent of total billed charges,,,548.68,,,per diem,,,46.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,46.79,,,percent of total billed charges,,,39.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.85,,,percent of total billed charges,,,46.79,,,percent of total billed charges,,,46.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.56,,,percent of total billed charges,,,37.86,,,percent of total billed charges,,,,,,,,,,,,,,,18.72,,,percent of total billed charges,,,,,,,,,17.31,,,percent of total billed charges,,,17.31,,,percent of total billed charges,,,,,,,,,46.79,,,percent of total billed charges,,,46.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.74,,,percent of total billed charges,,,46.79,,,percent of total billed charges,,,,,,,,,,,,,,,46.79,,,percent of total billed charges,,,46.79,,,percent of total billed charges,,,,,,,,,43.52,,,percent of total billed charges,,,,,,,,,,,,,,,43.52,,,percent of total billed charges,,,43.52,,,percent of total billed charges,,,43.52,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,46.79,,,percent of total billed charges,,,46.79,,,percent of total billed charges,,,46.79,,,percent of total billed charges,,,,,,,,,32.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,27.57,,,percent of total billed charges,,
OSELTAMIVIR 30 MG CAP,2500014691,CDM,637,RC,6818067511,NDC,999,EAPG,,,,outpatient,facility,30,UN,46.79,46.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXAZEPAM 10 MG CAP,2500014730,CDM,637,RC,6258481201,NDC,,,,,,inpatient,facility,10,UN,9.43,9.43,0.75,9.43,,,,,,,,,,,,,,9.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.43,,,percent of total billed charges,,,,,,,,,9.43,,,percent of total billed charges,,,4.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.66,,,percent of total billed charges,,,,,,,,,,,,,,,9.43,,,percent of total billed charges,,,8.02,,,percent of total billed charges,,,,,,,,,,,,,,,9.43,,,percent of total billed charges,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,9.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.56,,,percent of total billed charges,,
OXAZEPAM 10 MG CAP,2500014730,CDM,637,RC,6258481201,NDC,,,,,,outpatient,facility,10,UN,9.43,9.43,0.75,548.68,,6.69,,,percent of total billed charges,,,2.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.43,,,percent of total billed charges,,,5.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.45,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.43,,,fee schedule,,,9.43,,,percent of total billed charges,,,,,,,,,9.43,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.72,,,percent of total billed charges,,,,,,,,,,,,,,,5.09,,,percent of total billed charges,,,4.9,,,percent of total billed charges,,,5.19,,,percent of total billed charges,,,,,,,,,5.56,,,percent of total billed charges,,,548.68,,,per diem,,,9.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.43,,,percent of total billed charges,,,8.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,9.43,,,percent of total billed charges,,,9.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.36,,,percent of total billed charges,,,7.63,,,percent of total billed charges,,,,,,,,,,,,,,,3.77,,,percent of total billed charges,,,,,,,,,3.49,,,percent of total billed charges,,,3.49,,,percent of total billed charges,,,,,,,,,9.43,,,percent of total billed charges,,,9.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.75,,,percent of total billed charges,,,9.43,,,percent of total billed charges,,,,,,,,,,,,,,,9.43,,,percent of total billed charges,,,9.43,,,percent of total billed charges,,,,,,,,,8.77,,,percent of total billed charges,,,,,,,,,,,,,,,8.77,,,percent of total billed charges,,,8.77,,,percent of total billed charges,,,8.77,,,percent of total billed charges,,,7.07,,,percent of total billed charges,,,9.43,,,percent of total billed charges,,,9.43,,,percent of total billed charges,,,9.43,,,percent of total billed charges,,,,,,,,,6.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.56,,,percent of total billed charges,,
OXAZEPAM 10 MG CAP,2500014730,CDM,637,RC,6258481201,NDC,999,EAPG,,,,outpatient,facility,10,UN,9.43,9.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXAZEPAM 15 MG CAP,2500014732,CDM,637,RC,6258481301,NDC,,,,,,inpatient,facility,15,UN,10.39,10.39,0.83,10.39,,,,,,,,,,,,,,10.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.39,,,percent of total billed charges,,,,,,,,,10.39,,,percent of total billed charges,,,5.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,10.39,,,percent of total billed charges,,,8.83,,,percent of total billed charges,,,,,,,,,,,,,,,10.39,,,percent of total billed charges,,,5.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,
OXAZEPAM 15 MG CAP,2500014732,CDM,637,RC,6258481301,NDC,,,,,,outpatient,facility,15,UN,10.39,10.39,0.83,548.68,,7.37,,,percent of total billed charges,,,2.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.39,,,percent of total billed charges,,,6.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.8,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.39,,,fee schedule,,,10.39,,,percent of total billed charges,,,,,,,,,10.39,,,percent of total billed charges,,,6.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,5.71,,,percent of total billed charges,,,,,,,,,6.13,,,percent of total billed charges,,,548.68,,,per diem,,,10.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.39,,,percent of total billed charges,,,8.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.52,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.01,,,percent of total billed charges,,,8.41,,,percent of total billed charges,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,3.84,,,percent of total billed charges,,,3.84,,,percent of total billed charges,,,,,,,,,10.39,,,percent of total billed charges,,,10.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.83,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,,,,,,,,,,,,,10.39,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,,,,,,,9.66,,,percent of total billed charges,,,,,,,,,,,,,,,9.66,,,percent of total billed charges,,,9.66,,,percent of total billed charges,,,9.66,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,10.39,,,percent of total billed charges,,,,,,,,,7.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.12,,,percent of total billed charges,,
OXAZEPAM 15 MG CAP,2500014732,CDM,637,RC,6258481301,NDC,999,EAPG,,,,outpatient,facility,15,UN,10.39,10.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXCARBAZEPINE 150 MG TAB,2500014740,CDM,637,RC,6808484501,NDC,,,,,,inpatient,facility,150,UN,4.98,4.98,0.4,4.98,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,,,,,,,4.98,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,4.23,,,percent of total billed charges,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,
OXCARBAZEPINE 150 MG TAB,2500014740,CDM,637,RC,6808484501,NDC,,,,,,outpatient,facility,150,UN,4.98,4.98,0.4,548.68,,3.53,,,percent of total billed charges,,,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.98,,,percent of total billed charges,,,3.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.82,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.98,,,fee schedule,,,4.98,,,percent of total billed charges,,,,,,,,,4.98,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.55,,,percent of total billed charges,,,,,,,,,,,,,,,2.69,,,percent of total billed charges,,,2.59,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,,,,,,,2.94,,,percent of total billed charges,,,548.68,,,per diem,,,4.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.98,,,percent of total billed charges,,,4.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,,,,,,,1.84,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,4.98,,,percent of total billed charges,,,4.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.4,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,,,,,,,4.63,,,percent of total billed charges,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,4.63,,,percent of total billed charges,,,4.63,,,percent of total billed charges,,,3.74,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,4.98,,,percent of total billed charges,,,,,,,,,3.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.93,,,percent of total billed charges,,
OXCARBAZEPINE 150 MG TAB,2500014740,CDM,637,RC,6808484501,NDC,999,EAPG,,,,outpatient,facility,150,UN,4.98,4.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXCARBAZEPINE 300 MG TAB,2500014742,CDM,637,RC,6808485301,NDC,,,,,,inpatient,facility,300,UN,9.07,9.07,0.73,9.07,,,,,,,,,,,,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.07,,,percent of total billed charges,,,,,,,,,9.07,,,percent of total billed charges,,,4.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,,,,,,,,,,,,,9.07,,,percent of total billed charges,,,7.71,,,percent of total billed charges,,,,,,,,,,,,,,,9.07,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.34,,,percent of total billed charges,,
OXCARBAZEPINE 300 MG TAB,2500014742,CDM,637,RC,6808485301,NDC,,,,,,outpatient,facility,300,UN,9.07,9.07,0.73,548.68,,6.43,,,percent of total billed charges,,,2.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.07,,,percent of total billed charges,,,5.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.32,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.07,,,fee schedule,,,9.07,,,percent of total billed charges,,,,,,,,,9.07,,,percent of total billed charges,,,5.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.9,,,percent of total billed charges,,,4.72,,,percent of total billed charges,,,4.99,,,percent of total billed charges,,,,,,,,,5.35,,,percent of total billed charges,,,548.68,,,per diem,,,9.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.07,,,percent of total billed charges,,,7.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.82,,,percent of total billed charges,,,9.07,,,percent of total billed charges,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,7.34,,,percent of total billed charges,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,,,,,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,9.07,,,percent of total billed charges,,,9.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.73,,,percent of total billed charges,,,9.07,,,percent of total billed charges,,,,,,,,,,,,,,,9.07,,,percent of total billed charges,,,9.07,,,percent of total billed charges,,,,,,,,,8.44,,,percent of total billed charges,,,,,,,,,,,,,,,8.44,,,percent of total billed charges,,,8.44,,,percent of total billed charges,,,8.44,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,9.07,,,percent of total billed charges,,,9.07,,,percent of total billed charges,,,9.07,,,percent of total billed charges,,,,,,,,,6.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.34,,,percent of total billed charges,,
OXCARBAZEPINE 300 MG TAB,2500014742,CDM,637,RC,6808485301,NDC,999,EAPG,,,,outpatient,facility,300,UN,9.07,9.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYBUTYNIN 5 MG TAB,2500014760,CDM,637,RC,832003801,NDC,,,,,,inpatient,facility,5,UN,2.18,2.18,0.17,2.18,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,
OXYBUTYNIN 5 MG TAB,2500014760,CDM,637,RC,832003801,NDC,,,,,,outpatient,facility,5,UN,2.18,2.18,0.17,548.68,,1.55,,,percent of total billed charges,,,0.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.18,,,percent of total billed charges,,,1.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.8,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.18,,,fee schedule,,,2.18,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,548.68,,,per diem,,,2.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.18,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,0.81,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.28,,,percent of total billed charges,,
OXYBUTYNIN 5 MG TAB,2500014760,CDM,637,RC,832003801,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.18,2.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYCODONE 10 MG TABCR,2500014770,CDM,637,RC,5901141020,NDC,,,,,,inpatient,facility,10,UN,18.05,18.05,1.44,18.05,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,18.05,,,percent of total billed charges,,,9.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.83,,,percent of total billed charges,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,15.34,,,percent of total billed charges,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,9.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.64,,,percent of total billed charges,,
OXYCODONE 10 MG TABCR,2500014770,CDM,637,RC,5901141020,NDC,,,,,,outpatient,facility,10,UN,18.05,18.05,1.44,548.68,,12.8,,,percent of total billed charges,,,4.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,18.05,,,percent of total billed charges,,,11.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,12.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,12.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,18.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,18.05,,,fee schedule,,,18.05,,,percent of total billed charges,,,,,,,,,18.05,,,percent of total billed charges,,,11.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.86,,,percent of total billed charges,,,,,,,,,,,,,,,9.75,,,percent of total billed charges,,,9.39,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,10.65,,,percent of total billed charges,,,548.68,,,per diem,,,18.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,18.05,,,percent of total billed charges,,,15.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.59,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.18,,,percent of total billed charges,,,14.61,,,percent of total billed charges,,,,,,,,,,,,,,,7.22,,,percent of total billed charges,,,,,,,,,6.68,,,percent of total billed charges,,,6.68,,,percent of total billed charges,,,,,,,,,18.05,,,percent of total billed charges,,,18.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.44,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,16.79,,,percent of total billed charges,,,,,,,,,,,,,,,16.79,,,percent of total billed charges,,,16.79,,,percent of total billed charges,,,16.79,,,percent of total billed charges,,,13.54,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,12.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.03,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.64,,,percent of total billed charges,,
OXYCODONE 10 MG TABCR,2500014770,CDM,637,RC,5901141020,NDC,999,EAPG,,,,outpatient,facility,10,UN,18.05,18.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYCODONE 20 MG TABCR,2500014771,CDM,637,RC,5901142020,NDC,,,,,,inpatient,facility,20,UN,33.66,33.66,2.69,33.66,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,,,,,,,33.66,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,28.61,,,percent of total billed charges,,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,17.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,2.69,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.83,,,percent of total billed charges,,
OXYCODONE 20 MG TABCR,2500014771,CDM,637,RC,5901142020,NDC,,,,,,outpatient,facility,20,UN,33.66,33.66,2.69,548.68,,23.87,,,percent of total billed charges,,,8.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,33.66,,,percent of total billed charges,,,21.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,23.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,23.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.32,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,33.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,33.66,,,fee schedule,,,33.66,,,percent of total billed charges,,,,,,,,,33.66,,,percent of total billed charges,,,20.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.98,,,percent of total billed charges,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,18.51,,,percent of total billed charges,,,,,,,,,19.86,,,percent of total billed charges,,,548.68,,,per diem,,,33.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,33.66,,,percent of total billed charges,,,28.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.88,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.71,,,percent of total billed charges,,,27.24,,,percent of total billed charges,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,,,,,,,12.45,,,percent of total billed charges,,,12.45,,,percent of total billed charges,,,,,,,,,33.66,,,percent of total billed charges,,,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.69,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,,,,,,,31.31,,,percent of total billed charges,,,,,,,,,,,,,,,31.31,,,percent of total billed charges,,,31.31,,,percent of total billed charges,,,31.31,,,percent of total billed charges,,,25.24,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,33.66,,,percent of total billed charges,,,,,,,,,23.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,19.83,,,percent of total billed charges,,
OXYCODONE 20 MG TABCR,2500014771,CDM,637,RC,5901142020,NDC,999,EAPG,,,,outpatient,facility,20,UN,33.66,33.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYCODONE 40 MG TABCR,2500014772,CDM,637,RC,5901144020,NDC,,,,,,inpatient,facility,40,UN,57.62,57.62,4.61,57.62,,,,,,,,,,,,,,57.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.62,,,percent of total billed charges,,,,,,,,,57.62,,,percent of total billed charges,,,29.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.57,,,percent of total billed charges,,,,,,,,,,,,,,,57.62,,,percent of total billed charges,,,48.98,,,percent of total billed charges,,,,,,,,,,,,,,,57.62,,,percent of total billed charges,,,30.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,57.62,,,percent of total billed charges,,,,,,,,,,,,,,,4.61,,,percent of total billed charges,,,57.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.95,,,percent of total billed charges,,
OXYCODONE 40 MG TABCR,2500014772,CDM,637,RC,5901144020,NDC,,,,,,outpatient,facility,40,UN,57.62,57.62,4.61,548.68,,40.86,,,percent of total billed charges,,,14.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,57.62,,,percent of total billed charges,,,36.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,40.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,40.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,57.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,21.09,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,57.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,57.62,,,fee schedule,,,57.62,,,percent of total billed charges,,,,,,,,,57.62,,,percent of total billed charges,,,35.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.05,,,percent of total billed charges,,,,,,,,,,,,,,,31.11,,,percent of total billed charges,,,29.96,,,percent of total billed charges,,,31.69,,,percent of total billed charges,,,,,,,,,34,,,percent of total billed charges,,,548.68,,,per diem,,,57.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,57.62,,,percent of total billed charges,,,48.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.6,,,percent of total billed charges,,,57.62,,,percent of total billed charges,,,57.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.87,,,percent of total billed charges,,,46.63,,,percent of total billed charges,,,,,,,,,,,,,,,23.05,,,percent of total billed charges,,,,,,,,,21.32,,,percent of total billed charges,,,21.32,,,percent of total billed charges,,,,,,,,,57.62,,,percent of total billed charges,,,57.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,57.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.61,,,percent of total billed charges,,,57.62,,,percent of total billed charges,,,,,,,,,,,,,,,57.62,,,percent of total billed charges,,,57.62,,,percent of total billed charges,,,,,,,,,53.6,,,percent of total billed charges,,,,,,,,,,,,,,,53.6,,,percent of total billed charges,,,53.6,,,percent of total billed charges,,,53.6,,,percent of total billed charges,,,43.21,,,percent of total billed charges,,,57.62,,,percent of total billed charges,,,57.62,,,percent of total billed charges,,,57.62,,,percent of total billed charges,,,,,,,,,40.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,33.95,,,percent of total billed charges,,
OXYCODONE 40 MG TABCR,2500014772,CDM,637,RC,5901144020,NDC,999,EAPG,,,,outpatient,facility,40,UN,57.62,57.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYCODONE 5 MG/5 ML UDC,2500014775,CDM,637,RC,904682894,NDC,,,,,,inpatient,facility,5,UN,14.49,14.49,1.16,14.49,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,14.49,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.69,,,percent of total billed charges,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,12.32,,,percent of total billed charges,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,7.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.54,,,percent of total billed charges,,
OXYCODONE 5 MG/5 ML UDC,2500014775,CDM,637,RC,904682894,NDC,,,,,,outpatient,facility,5,UN,14.49,14.49,1.16,548.68,,10.27,,,percent of total billed charges,,,3.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.49,,,percent of total billed charges,,,9.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.49,,,fee schedule,,,14.49,,,percent of total billed charges,,,,,,,,,14.49,,,percent of total billed charges,,,8.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.32,,,percent of total billed charges,,,,,,,,,,,,,,,7.82,,,percent of total billed charges,,,7.53,,,percent of total billed charges,,,7.97,,,percent of total billed charges,,,,,,,,,8.55,,,percent of total billed charges,,,548.68,,,per diem,,,14.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.49,,,percent of total billed charges,,,12.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.7,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.77,,,percent of total billed charges,,,11.73,,,percent of total billed charges,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,,,,,,,5.36,,,percent of total billed charges,,,5.36,,,percent of total billed charges,,,,,,,,,14.49,,,percent of total billed charges,,,14.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.16,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,13.48,,,percent of total billed charges,,,,,,,,,,,,,,,13.48,,,percent of total billed charges,,,13.48,,,percent of total billed charges,,,13.48,,,percent of total billed charges,,,10.87,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,10.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.54,,,percent of total billed charges,,
OXYCODONE 5 MG/5 ML UDC,2500014775,CDM,637,RC,904682894,NDC,999,EAPG,,,,outpatient,facility,5,UN,14.49,14.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYCODONE 15 MG TABCR,2500014789,CDM,637,RC,5901141520,NDC,,,,,,inpatient,facility,15,UN,26.57,26.57,2.13,26.57,,,,,,,,,,,,,,26.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.57,,,percent of total billed charges,,,,,,,,,26.57,,,percent of total billed charges,,,13.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.94,,,percent of total billed charges,,,,,,,,,,,,,,,26.57,,,percent of total billed charges,,,22.58,,,percent of total billed charges,,,,,,,,,,,,,,,26.57,,,percent of total billed charges,,,14.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,26.57,,,percent of total billed charges,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,26.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.66,,,percent of total billed charges,,
OXYCODONE 15 MG TABCR,2500014789,CDM,637,RC,5901141520,NDC,,,,,,outpatient,facility,15,UN,26.57,26.57,2.13,548.68,,18.84,,,percent of total billed charges,,,6.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,26.57,,,percent of total billed charges,,,16.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,18.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,18.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,26.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.72,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,26.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,26.57,,,fee schedule,,,26.57,,,percent of total billed charges,,,,,,,,,26.57,,,percent of total billed charges,,,16.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.93,,,percent of total billed charges,,,,,,,,,,,,,,,14.35,,,percent of total billed charges,,,13.82,,,percent of total billed charges,,,14.61,,,percent of total billed charges,,,,,,,,,15.68,,,percent of total billed charges,,,548.68,,,per diem,,,26.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,26.57,,,percent of total billed charges,,,22.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.11,,,percent of total billed charges,,,26.57,,,percent of total billed charges,,,26.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.92,,,percent of total billed charges,,,21.5,,,percent of total billed charges,,,,,,,,,,,,,,,10.63,,,percent of total billed charges,,,,,,,,,9.83,,,percent of total billed charges,,,9.83,,,percent of total billed charges,,,,,,,,,26.57,,,percent of total billed charges,,,26.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.13,,,percent of total billed charges,,,26.57,,,percent of total billed charges,,,,,,,,,,,,,,,26.57,,,percent of total billed charges,,,26.57,,,percent of total billed charges,,,,,,,,,24.72,,,percent of total billed charges,,,,,,,,,,,,,,,24.72,,,percent of total billed charges,,,24.72,,,percent of total billed charges,,,24.72,,,percent of total billed charges,,,19.93,,,percent of total billed charges,,,26.57,,,percent of total billed charges,,,26.57,,,percent of total billed charges,,,26.57,,,percent of total billed charges,,,,,,,,,18.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15.66,,,percent of total billed charges,,
OXYCODONE 15 MG TABCR,2500014789,CDM,637,RC,5901141520,NDC,999,EAPG,,,,outpatient,facility,15,UN,26.57,26.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYMETAZOLINE 0.05  NASAL 15ML,2500014790,CDM,637,RC,4110081123,NDC,,,,,,inpatient,facility,15,UN,9.16,9.16,0.73,9.16,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,,,,,,,9.16,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.5,,,percent of total billed charges,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,4.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.4,,,percent of total billed charges,,
OXYMETAZOLINE 0.05  NASAL 15ML,2500014790,CDM,637,RC,4110081123,NDC,,,,,,outpatient,facility,15,UN,9.16,9.16,0.73,548.68,,6.5,,,percent of total billed charges,,,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.16,,,percent of total billed charges,,,5.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.35,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.16,,,fee schedule,,,9.16,,,percent of total billed charges,,,,,,,,,9.16,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.53,,,percent of total billed charges,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,4.76,,,percent of total billed charges,,,5.04,,,percent of total billed charges,,,,,,,,,5.4,,,percent of total billed charges,,,548.68,,,per diem,,,9.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.16,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.86,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.18,,,percent of total billed charges,,,7.41,,,percent of total billed charges,,,,,,,,,,,,,,,3.66,,,percent of total billed charges,,,,,,,,,3.39,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,9.16,,,percent of total billed charges,,,9.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.73,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,,,,,,,8.52,,,percent of total billed charges,,,,,,,,,,,,,,,8.52,,,percent of total billed charges,,,8.52,,,percent of total billed charges,,,8.52,,,percent of total billed charges,,,6.87,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,9.16,,,percent of total billed charges,,,,,,,,,6.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.4,,,percent of total billed charges,,
OXYMETAZOLINE 0.05  NASAL 15ML,2500014790,CDM,637,RC,4110081123,NDC,999,EAPG,,,,outpatient,facility,15,UN,9.16,9.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXYMETAZOLINE 0.05  NASAL 30ML,2500014793,CDM,637,RC,904676130,NDC,,,,,,inpatient,facility,30,UN,7.39,7.39,0.59,7.39,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,,,,,,,7.39,,,percent of total billed charges,,,3.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.43,,,percent of total billed charges,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,6.28,,,percent of total billed charges,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.35,,,percent of total billed charges,,
OXYMETAZOLINE 0.05  NASAL 30ML,2500014793,CDM,637,RC,904676130,NDC,,,,,,outpatient,facility,30,UN,7.39,7.39,0.59,548.68,,5.24,,,percent of total billed charges,,,1.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.39,,,percent of total billed charges,,,4.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.7,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.39,,,fee schedule,,,7.39,,,percent of total billed charges,,,,,,,,,7.39,,,percent of total billed charges,,,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,3.84,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,,,,,,,4.36,,,percent of total billed charges,,,548.68,,,per diem,,,7.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.39,,,percent of total billed charges,,,6.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.99,,,percent of total billed charges,,,5.98,,,percent of total billed charges,,,,,,,,,,,,,,,2.96,,,percent of total billed charges,,,,,,,,,2.73,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,,,,,,,7.39,,,percent of total billed charges,,,7.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.59,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,6.87,,,percent of total billed charges,,,,,,,,,,,,,,,6.87,,,percent of total billed charges,,,6.87,,,percent of total billed charges,,,6.87,,,percent of total billed charges,,,5.54,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.35,,,percent of total billed charges,,
OXYMETAZOLINE 0.05  NASAL 30ML,2500014793,CDM,637,RC,904676130,NDC,999,EAPG,,,,outpatient,facility,30,UN,7.39,7.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PANTOPRAZOLE 40 MG TABEC,2500014840,CDM,637,RC,904647461,NDC,,,,,,inpatient,facility,20,UN,0.99,0.99,0.08,0.99,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
PANTOPRAZOLE 40 MG TABEC,2500014840,CDM,637,RC,904647461,NDC,,,,,,outpatient,facility,20,UN,0.99,0.99,0.08,548.68,,0.7,,,percent of total billed charges,,,0.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.99,,,percent of total billed charges,,,0.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.99,,,fee schedule,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,0.58,,,percent of total billed charges,,,548.68,,,per diem,,,0.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.99,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,0.37,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
PANTOPRAZOLE 40 MG TABEC,2500014840,CDM,637,RC,904647461,NDC,999,EAPG,,,,outpatient,facility,20,UN,0.99,0.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PANTOPRAZOLE 40 MG SUSP PKT,2500014841,CDM,637,RC,6275607164,NDC,,,,,,inpatient,facility,40,UN,46.73,46.73,3.74,46.73,,,,,,,,,,,,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.73,,,percent of total billed charges,,,,,,,,,46.73,,,percent of total billed charges,,,23.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.04,,,percent of total billed charges,,,,,,,,,,,,,,,46.73,,,percent of total billed charges,,,39.72,,,percent of total billed charges,,,,,,,,,,,,,,,46.73,,,percent of total billed charges,,,24.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,3.74,,,percent of total billed charges,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.53,,,percent of total billed charges,,
PANTOPRAZOLE 40 MG SUSP PKT,2500014841,CDM,637,RC,6275607164,NDC,,,,,,outpatient,facility,40,UN,46.73,46.73,3.74,548.68,,33.14,,,percent of total billed charges,,,11.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,46.73,,,percent of total billed charges,,,29.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,32.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,32.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,17.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,46.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,46.73,,,fee schedule,,,46.73,,,percent of total billed charges,,,,,,,,,46.73,,,percent of total billed charges,,,28.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.3,,,percent of total billed charges,,,,,,,,,,,,,,,25.23,,,percent of total billed charges,,,24.3,,,percent of total billed charges,,,25.7,,,percent of total billed charges,,,,,,,,,27.57,,,percent of total billed charges,,,548.68,,,per diem,,,46.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,46.73,,,percent of total billed charges,,,39.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.82,,,percent of total billed charges,,,46.73,,,percent of total billed charges,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.52,,,percent of total billed charges,,,37.81,,,percent of total billed charges,,,,,,,,,,,,,,,18.69,,,percent of total billed charges,,,,,,,,,17.29,,,percent of total billed charges,,,17.29,,,percent of total billed charges,,,,,,,,,46.73,,,percent of total billed charges,,,46.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.74,,,percent of total billed charges,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,46.73,,,percent of total billed charges,,,46.73,,,percent of total billed charges,,,,,,,,,43.47,,,percent of total billed charges,,,,,,,,,,,,,,,43.47,,,percent of total billed charges,,,43.47,,,percent of total billed charges,,,43.47,,,percent of total billed charges,,,35.05,,,percent of total billed charges,,,46.73,,,percent of total billed charges,,,46.73,,,percent of total billed charges,,,46.73,,,percent of total billed charges,,,,,,,,,32.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,27.53,,,percent of total billed charges,,
PANTOPRAZOLE 40 MG SUSP PKT,2500014841,CDM,637,RC,6275607164,NDC,999,EAPG,,,,outpatient,facility,40,UN,46.73,46.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PANTOPRAZOLE 40 MG/10 ML INJ,2500014843,CDM,636,RC,J2470,HCPCS,5515020210,NDC,,,,inpatient,facility,40,UN,28.05,28.05,2.24,28.05,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,28.05,,,percent of total billed charges,,,14.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.83,,,percent of total billed charges,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,23.84,,,percent of total billed charges,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,14.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.53,,,percent of total billed charges,,
PANTOPRAZOLE 40 MG/10 ML INJ,2500014843,CDM,636,RC,J2470,HCPCS,5515020210,NDC,,,,outpatient,facility,40,UN,28.05,28.05,2.24,548.68,,19.89,,,percent of total billed charges,,,6.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,28.05,,,percent of total billed charges,,,6.74,,,fee schedule,,,6.37,,,fee schedule,,,,,,,,,6.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.27,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,28.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,28.05,,,fee schedule,,,28.05,,,percent of total billed charges,,,,,,,,,28.05,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.99,,,percent of total billed charges,,,,,,,,,,,,,,,15.15,,,percent of total billed charges,,,14.59,,,percent of total billed charges,,,15.43,,,percent of total billed charges,,,,,,,,,16.55,,,percent of total billed charges,,,548.68,,,per diem,,,28.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,28.05,,,percent of total billed charges,,,23.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.9,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.92,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,,,,,,,,,,,,,11.22,,,percent of total billed charges,,,,,,,,,10.38,,,percent of total billed charges,,,10.38,,,percent of total billed charges,,,,,,,,,28.05,,,percent of total billed charges,,,28.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.24,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,26.09,,,percent of total billed charges,,,,,,,,,,,,,,,26.09,,,percent of total billed charges,,,26.09,,,percent of total billed charges,,,26.09,,,percent of total billed charges,,,21.04,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,19.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.03,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,16.53,,,percent of total billed charges,,
PANTOPRAZOLE 40 MG/10 ML INJ,2500014843,CDM,636,RC,J2470,HCPCS,5515020210,NDC,496,EAPG,,outpatient,facility,40,UN,28.05,28.05,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PAROXETINE HCL 10 MG TAB,2500014940,CDM,637,RC,5026864015,NDC,,,,,,inpatient,facility,10,UN,2.54,2.54,0.2,2.54,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,2.54,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,
PAROXETINE HCL 10 MG TAB,2500014940,CDM,637,RC,5026864015,NDC,,,,,,outpatient,facility,10,UN,2.54,2.54,0.2,548.68,,1.8,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.54,,,percent of total billed charges,,,1.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.93,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.54,,,fee schedule,,,2.54,,,percent of total billed charges,,,,,,,,,2.54,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,,,,,,,1.5,,,percent of total billed charges,,,548.68,,,per diem,,,2.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.54,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,0.94,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,,,,,,,2.54,,,percent of total billed charges,,,2.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.5,,,percent of total billed charges,,
PAROXETINE HCL 10 MG TAB,2500014940,CDM,637,RC,5026864015,NDC,999,EAPG,,,,outpatient,facility,10,UN,2.54,2.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PAROXETINE HCL 20 MG TAB,2500014942,CDM,637,RC,904567761,NDC,,,,,,inpatient,facility,20,UN,0.82,0.82,0.07,0.82,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,
PAROXETINE HCL 20 MG TAB,2500014942,CDM,637,RC,904567761,NDC,,,,,,outpatient,facility,20,UN,0.82,0.82,0.07,548.68,,0.58,,,percent of total billed charges,,,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.82,,,percent of total billed charges,,,0.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.82,,,fee schedule,,,0.82,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,0.48,,,percent of total billed charges,,,548.68,,,per diem,,,0.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.82,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,0.3,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.48,,,percent of total billed charges,,
PAROXETINE HCL 20 MG TAB,2500014942,CDM,637,RC,904567761,NDC,999,EAPG,,,,outpatient,facility,20,UN,0.82,0.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PENICILLIN VK 250 MG TAB,2500015012,CDM,637,RC,6586217501,NDC,,,,,,inpatient,facility,250,UN,1.52,1.52,0.12,1.52,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,
PENICILLIN VK 250 MG TAB,2500015012,CDM,637,RC,6586217501,NDC,,,,,,outpatient,facility,250,UN,1.52,1.52,0.12,548.68,,1.08,,,percent of total billed charges,,,0.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.52,,,percent of total billed charges,,,0.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.52,,,fee schedule,,,1.52,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,0.9,,,percent of total billed charges,,,548.68,,,per diem,,,1.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.52,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,1.52,,,percent of total billed charges,,,1.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.9,,,percent of total billed charges,,
PENICILLIN VK 250 MG TAB,2500015012,CDM,637,RC,6586217501,NDC,999,EAPG,,,,outpatient,facility,250,UN,1.52,1.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PENICILLIN VK 250 MG/5 ML,2500015017,CDM,637,RC,93412773,NDC,,,,,,inpatient,facility,5,UN,1.85,1.85,0.15,1.85,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,
PENICILLIN VK 250 MG/5 ML,2500015017,CDM,637,RC,93412773,NDC,,,,,,outpatient,facility,5,UN,1.85,1.85,0.15,548.68,,1.31,,,percent of total billed charges,,,0.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.85,,,percent of total billed charges,,,1.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.68,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.85,,,fee schedule,,,1.85,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,548.68,,,per diem,,,1.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.85,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.09,,,percent of total billed charges,,
PENICILLIN VK 250 MG/5 ML,2500015017,CDM,637,RC,93412773,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.85,1.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PENTOXIFYLLINE 400 MG TABCR,2500015040,CDM,637,RC,904544861,NDC,,,,,,inpatient,facility,400,UN,0.83,0.83,0.07,0.83,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,
PENTOXIFYLLINE 400 MG TABCR,2500015040,CDM,637,RC,904544861,NDC,,,,,,outpatient,facility,400,UN,0.83,0.83,0.07,548.68,,0.59,,,percent of total billed charges,,,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.83,,,percent of total billed charges,,,0.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.83,,,fee schedule,,,0.83,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,548.68,,,per diem,,,0.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.83,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,0.31,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,0.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.49,,,percent of total billed charges,,
PENTOXIFYLLINE 400 MG TABCR,2500015040,CDM,637,RC,904544861,NDC,999,EAPG,,,,outpatient,facility,400,UN,0.83,0.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PERMETHRIN 5  CR 60 GM,2500015070,CDM,637,RC,2192202107,NDC,,,,,,inpatient,facility,60,UN,389.4,389.4,31.15,389.4,,,,,,,,,,,,,,389.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,389.4,,,percent of total billed charges,,,,,,,,,389.4,,,percent of total billed charges,,,198.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.64,,,percent of total billed charges,,,,,,,,,,,,,,,389.4,,,percent of total billed charges,,,330.99,,,percent of total billed charges,,,,,,,,,,,,,,,389.4,,,percent of total billed charges,,,206.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,389.4,,,percent of total billed charges,,,,,,,,,,,,,,,31.15,,,percent of total billed charges,,,389.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,389.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,229.43,,,percent of total billed charges,,
PERMETHRIN 5  CR 60 GM,2500015070,CDM,637,RC,2192202107,NDC,,,,,,outpatient,facility,60,UN,389.4,389.4,31.15,548.68,,276.12,,,percent of total billed charges,,,95.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,389.4,,,percent of total billed charges,,,244.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,273.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,273.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,389.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,142.52,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,389.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,389.4,,,fee schedule,,,389.4,,,percent of total billed charges,,,,,,,,,389.4,,,percent of total billed charges,,,238.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,277.45,,,percent of total billed charges,,,,,,,,,,,,,,,210.28,,,percent of total billed charges,,,202.49,,,percent of total billed charges,,,214.17,,,percent of total billed charges,,,,,,,,,229.75,,,percent of total billed charges,,,548.68,,,per diem,,,389.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,389.4,,,percent of total billed charges,,,330.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,206.81,,,percent of total billed charges,,,389.4,,,percent of total billed charges,,,389.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.69,,,percent of total billed charges,,,315.1,,,percent of total billed charges,,,,,,,,,,,,,,,155.76,,,percent of total billed charges,,,,,,,,,144.08,,,percent of total billed charges,,,144.08,,,percent of total billed charges,,,,,,,,,389.4,,,percent of total billed charges,,,389.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,389.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.15,,,percent of total billed charges,,,389.4,,,percent of total billed charges,,,,,,,,,,,,,,,389.4,,,percent of total billed charges,,,389.4,,,percent of total billed charges,,,,,,,,,362.22,,,percent of total billed charges,,,,,,,,,,,,,,,362.22,,,percent of total billed charges,,,362.22,,,percent of total billed charges,,,362.22,,,percent of total billed charges,,,292.05,,,percent of total billed charges,,,389.4,,,percent of total billed charges,,,389.4,,,percent of total billed charges,,,389.4,,,percent of total billed charges,,,,,,,,,273.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,229.43,,,percent of total billed charges,,
PERMETHRIN 5  CR 60 GM,2500015070,CDM,637,RC,2192202107,NDC,999,EAPG,,,,outpatient,facility,60,UN,389.4,389.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PERMETHRIN CR RINSE 1  60 ML,2500015075,CDM,637,RC,6373612002,NDC,,,,,,inpatient,facility,60,UN,23.76,23.76,1.9,23.76,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,23.76,,,percent of total billed charges,,,12.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,12.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14,,,percent of total billed charges,,
PERMETHRIN CR RINSE 1  60 ML,2500015075,CDM,637,RC,6373612002,NDC,,,,,,outpatient,facility,60,UN,23.76,23.76,1.9,548.68,,16.85,,,percent of total billed charges,,,5.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,23.76,,,percent of total billed charges,,,14.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,16.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,16.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.7,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,23.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,23.76,,,fee schedule,,,23.76,,,percent of total billed charges,,,,,,,,,23.76,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.93,,,percent of total billed charges,,,,,,,,,,,,,,,12.83,,,percent of total billed charges,,,12.36,,,percent of total billed charges,,,13.07,,,percent of total billed charges,,,,,,,,,14.02,,,percent of total billed charges,,,548.68,,,per diem,,,23.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,23.76,,,percent of total billed charges,,,20.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.62,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.03,,,percent of total billed charges,,,19.23,,,percent of total billed charges,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,,,,,,,8.79,,,percent of total billed charges,,,8.79,,,percent of total billed charges,,,,,,,,,23.76,,,percent of total billed charges,,,23.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.9,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,,,,,,,,,,,,,23.76,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,,,,,,,22.1,,,percent of total billed charges,,,,,,,,,,,,,,,22.1,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,,,,,,,16.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14,,,percent of total billed charges,,
PERMETHRIN CR RINSE 1  60 ML,2500015075,CDM,637,RC,6373612002,NDC,999,EAPG,,,,outpatient,facility,60,UN,23.76,23.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PETROLATUM OPH OINT 3.5 GM,2500015113,CDM,637,RC,23024004,NDC,,,,,,inpatient,facility,3.5,UN,13.76,13.76,1.1,13.76,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,13.76,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.26,,,percent of total billed charges,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,11.7,,,percent of total billed charges,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,7.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.11,,,percent of total billed charges,,
PETROLATUM OPH OINT 3.5 GM,2500015113,CDM,637,RC,23024004,NDC,,,,,,outpatient,facility,3.5,UN,13.76,13.76,1.1,548.68,,9.76,,,percent of total billed charges,,,3.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.76,,,percent of total billed charges,,,8.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.04,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.76,,,fee schedule,,,13.76,,,percent of total billed charges,,,,,,,,,13.76,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.8,,,percent of total billed charges,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,7.57,,,percent of total billed charges,,,,,,,,,8.12,,,percent of total billed charges,,,548.68,,,per diem,,,13.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.76,,,percent of total billed charges,,,11.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.31,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.28,,,percent of total billed charges,,,11.13,,,percent of total billed charges,,,,,,,,,,,,,,,5.5,,,percent of total billed charges,,,,,,,,,5.09,,,percent of total billed charges,,,5.09,,,percent of total billed charges,,,,,,,,,13.76,,,percent of total billed charges,,,13.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.1,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,,,,,,,12.8,,,percent of total billed charges,,,,,,,,,,,,,,,12.8,,,percent of total billed charges,,,12.8,,,percent of total billed charges,,,12.8,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,,,,,,,9.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.11,,,percent of total billed charges,,
PETROLATUM OPH OINT 3.5 GM,2500015113,CDM,637,RC,23024004,NDC,999,EAPG,,,,outpatient,facility,3.5,UN,13.76,13.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENAZOPYRIDINE HCL 100 MG TAB,2500015120,CDM,637,RC,7582611410,NDC,,,,,,inpatient,facility,100,UN,7.92,7.92,0.63,7.92,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,7.92,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,6.73,,,percent of total billed charges,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.67,,,percent of total billed charges,,
PHENAZOPYRIDINE HCL 100 MG TAB,2500015120,CDM,637,RC,7582611410,NDC,,,,,,outpatient,facility,100,UN,7.92,7.92,0.63,548.68,,5.62,,,percent of total billed charges,,,1.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.92,,,percent of total billed charges,,,4.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.9,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.92,,,fee schedule,,,7.92,,,percent of total billed charges,,,,,,,,,7.92,,,percent of total billed charges,,,4.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,4.12,,,percent of total billed charges,,,4.36,,,percent of total billed charges,,,,,,,,,4.67,,,percent of total billed charges,,,548.68,,,per diem,,,7.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.92,,,percent of total billed charges,,,6.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.21,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.34,,,percent of total billed charges,,,6.41,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,2.93,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,7.92,,,percent of total billed charges,,,7.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.63,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,7.37,,,percent of total billed charges,,,,,,,,,,,,,,,7.37,,,percent of total billed charges,,,7.37,,,percent of total billed charges,,,7.37,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,5.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.67,,,percent of total billed charges,,
PHENAZOPYRIDINE HCL 100 MG TAB,2500015120,CDM,637,RC,7582611410,NDC,999,EAPG,,,,outpatient,facility,100,UN,7.92,7.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENOBARBITAL 100 MG TAB,2500015140,CDM,637,RC,1351710716,NDC,,,,,,inpatient,facility,20,UN,2.05,2.05,0.16,2.05,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,2.05,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,
PHENOBARBITAL 100 MG TAB,2500015140,CDM,637,RC,1351710716,NDC,,,,,,outpatient,facility,20,UN,2.05,2.05,0.16,548.68,,1.45,,,percent of total billed charges,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.05,,,percent of total billed charges,,,1.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.75,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.05,,,fee schedule,,,2.05,,,percent of total billed charges,,,,,,,,,2.05,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.46,,,percent of total billed charges,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,1.21,,,percent of total billed charges,,,548.68,,,per diem,,,2.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.05,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,2.05,,,percent of total billed charges,,,2.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,2.05,,,percent of total billed charges,,,,,,,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.21,,,percent of total billed charges,,
PHENOBARBITAL 100 MG TAB,2500015140,CDM,637,RC,1351710716,NDC,999,EAPG,,,,outpatient,facility,20,UN,2.05,2.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENOBARBITAL 32.4 MG TAB,2500015144,CDM,637,RC,904657561,NDC,,,,,,inpatient,facility,32.4,UN,1.25,1.25,0.1,1.25,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,
PHENOBARBITAL 32.4 MG TAB,2500015144,CDM,637,RC,904657561,NDC,,,,,,outpatient,facility,32.4,UN,1.25,1.25,0.1,548.68,,0.89,,,percent of total billed charges,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.25,,,percent of total billed charges,,,0.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.25,,,fee schedule,,,1.25,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,548.68,,,per diem,,,1.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.25,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.74,,,percent of total billed charges,,
PHENOBARBITAL 32.4 MG TAB,2500015144,CDM,637,RC,904657561,NDC,999,EAPG,,,,outpatient,facility,32.4,UN,1.25,1.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENOBARBITAL 20 MG/5 ML UDC,2500015146,CDM,637,RC,1657167516,NDC,,,,,,inpatient,facility,5,UN,3.36,3.36,0.27,3.36,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,3.36,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,
PHENOBARBITAL 20 MG/5 ML UDC,2500015146,CDM,637,RC,1657167516,NDC,,,,,,outpatient,facility,5,UN,3.36,3.36,0.27,548.68,,2.38,,,percent of total billed charges,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.36,,,percent of total billed charges,,,2.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.36,,,fee schedule,,,3.36,,,percent of total billed charges,,,,,,,,,3.36,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,1.98,,,percent of total billed charges,,,548.68,,,per diem,,,3.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.36,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.27,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,1.24,,,percent of total billed charges,,,1.24,,,percent of total billed charges,,,,,,,,,3.36,,,percent of total billed charges,,,3.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.27,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.98,,,percent of total billed charges,,
PHENOBARBITAL 20 MG/5 ML UDC,2500015146,CDM,637,RC,1657167516,NDC,999,EAPG,,,,outpatient,facility,5,UN,3.36,3.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENOL 1.4  SOLN 180 ML,2500015150,CDM,637,RC,904630521,NDC,,,,,,inpatient,facility,180,UN,4.04,4.04,0.32,4.04,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,,,,,,,4.04,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.42,,,percent of total billed charges,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,
PHENOL 1.4  SOLN 180 ML,2500015150,CDM,637,RC,904630521,NDC,,,,,,outpatient,facility,180,UN,4.04,4.04,0.32,548.68,,2.86,,,percent of total billed charges,,,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.04,,,percent of total billed charges,,,2.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.48,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.04,,,fee schedule,,,4.04,,,percent of total billed charges,,,,,,,,,4.04,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.88,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.1,,,percent of total billed charges,,,2.22,,,percent of total billed charges,,,,,,,,,2.38,,,percent of total billed charges,,,548.68,,,per diem,,,4.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.04,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.73,,,percent of total billed charges,,,3.27,,,percent of total billed charges,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,1.49,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,4.04,,,percent of total billed charges,,,4.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.32,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,2.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.38,,,percent of total billed charges,,
PHENOL 1.4  SOLN 180 ML,2500015150,CDM,637,RC,904630521,NDC,999,EAPG,,,,outpatient,facility,180,UN,4.04,4.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRINE 0.25  NASAL 15ML,2500015201,CDM,637,RC,225080047,NDC,,,,,,inpatient,facility,15,UN,5.21,5.21,0.42,5.21,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,,,,,,,5.21,,,percent of total billed charges,,,2.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,4.43,,,percent of total billed charges,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,
PHENYLEPHRINE 0.25  NASAL 15ML,2500015201,CDM,637,RC,225080047,NDC,,,,,,outpatient,facility,15,UN,5.21,5.21,0.42,548.68,,3.69,,,percent of total billed charges,,,1.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.21,,,percent of total billed charges,,,3.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.21,,,fee schedule,,,5.21,,,percent of total billed charges,,,,,,,,,5.21,,,percent of total billed charges,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.71,,,percent of total billed charges,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,2.71,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,3.07,,,percent of total billed charges,,,548.68,,,per diem,,,5.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.21,,,percent of total billed charges,,,4.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,1.93,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,,,,,,,5.21,,,percent of total billed charges,,,5.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.42,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,,,,,,,,,,,,,5.21,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,,,,,,,4.85,,,percent of total billed charges,,,,,,,,,,,,,,,4.85,,,percent of total billed charges,,,4.85,,,percent of total billed charges,,,4.85,,,percent of total billed charges,,,3.91,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,5.21,,,percent of total billed charges,,,,,,,,,3.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.07,,,percent of total billed charges,,
PHENYLEPHRINE 0.25  NASAL 15ML,2500015201,CDM,637,RC,225080047,NDC,999,EAPG,,,,outpatient,facility,15,UN,5.21,5.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRINE 0.5  NASAL 15ML,2500015202,CDM,637,RC,225080547,NDC,,,,,,inpatient,facility,15,UN,4.91,4.91,0.39,4.91,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,4.91,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,4.17,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,,percent of total billed charges,,
PHENYLEPHRINE 0.5  NASAL 15ML,2500015202,CDM,637,RC,225080547,NDC,,,,,,outpatient,facility,15,UN,4.91,4.91,0.39,548.68,,3.48,,,percent of total billed charges,,,1.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.91,,,percent of total billed charges,,,3.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.8,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.91,,,fee schedule,,,4.91,,,percent of total billed charges,,,,,,,,,4.91,,,percent of total billed charges,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,,,,,,,2.9,,,percent of total billed charges,,,548.68,,,per diem,,,4.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.91,,,percent of total billed charges,,,4.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.61,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,,3.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,1.82,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,4.91,,,percent of total billed charges,,,4.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.39,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,4.57,,,percent of total billed charges,,,,,,,,,,,,,,,4.57,,,percent of total billed charges,,,4.57,,,percent of total billed charges,,,4.57,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.89,,,percent of total billed charges,,
PHENYLEPHRINE 0.5  NASAL 15ML,2500015202,CDM,637,RC,225080547,NDC,999,EAPG,,,,outpatient,facility,15,UN,4.91,4.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRINE 2.5  OPH 2 ML,2500015213,CDM,637,RC,1747820102,NDC,,,,,,inpatient,facility,2,UN,134.08,134.08,10.73,134.08,,,,,,,,,,,,,,134.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.08,,,percent of total billed charges,,,,,,,,,134.08,,,percent of total billed charges,,,68.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.45,,,percent of total billed charges,,,,,,,,,,,,,,,134.08,,,percent of total billed charges,,,113.97,,,percent of total billed charges,,,,,,,,,,,,,,,134.08,,,percent of total billed charges,,,71.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,134.08,,,percent of total billed charges,,,,,,,,,,,,,,,10.73,,,percent of total billed charges,,,134.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,134.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79,,,percent of total billed charges,,
PHENYLEPHRINE 2.5  OPH 2 ML,2500015213,CDM,637,RC,1747820102,NDC,,,,,,outpatient,facility,2,UN,134.08,134.08,10.73,548.68,,95.08,,,percent of total billed charges,,,32.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,134.08,,,percent of total billed charges,,,84.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,94.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,94.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,134.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,49.07,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,134.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,134.08,,,fee schedule,,,134.08,,,percent of total billed charges,,,,,,,,,134.08,,,percent of total billed charges,,,82.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.53,,,percent of total billed charges,,,,,,,,,,,,,,,72.4,,,percent of total billed charges,,,69.72,,,percent of total billed charges,,,73.74,,,percent of total billed charges,,,,,,,,,79.11,,,percent of total billed charges,,,548.68,,,per diem,,,134.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,134.08,,,percent of total billed charges,,,113.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.21,,,percent of total billed charges,,,134.08,,,percent of total billed charges,,,134.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.45,,,percent of total billed charges,,,108.5,,,percent of total billed charges,,,,,,,,,,,,,,,53.63,,,percent of total billed charges,,,,,,,,,49.61,,,percent of total billed charges,,,49.61,,,percent of total billed charges,,,,,,,,,134.08,,,percent of total billed charges,,,134.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,134.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.73,,,percent of total billed charges,,,134.08,,,percent of total billed charges,,,,,,,,,,,,,,,134.08,,,percent of total billed charges,,,134.08,,,percent of total billed charges,,,,,,,,,124.72,,,percent of total billed charges,,,,,,,,,,,,,,,124.72,,,percent of total billed charges,,,124.72,,,percent of total billed charges,,,124.72,,,percent of total billed charges,,,100.56,,,percent of total billed charges,,,134.08,,,percent of total billed charges,,,134.08,,,percent of total billed charges,,,134.08,,,percent of total billed charges,,,,,,,,,94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,79,,,percent of total billed charges,,
PHENYLEPHRINE 2.5  OPH 2 ML,2500015213,CDM,637,RC,1747820102,NDC,999,EAPG,,,,outpatient,facility,2,UN,134.08,134.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYLEPHRINE 2.5  OPH 15ML,2500015214,CDM,637,RC,1747820115,NDC,,,,,,inpatient,facility,15,UN,371.25,371.25,29.7,371.25,,,,,,,,,,,,,,371.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.25,,,percent of total billed charges,,,,,,,,,371.25,,,percent of total billed charges,,,189.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.75,,,percent of total billed charges,,,,,,,,,,,,,,,371.25,,,percent of total billed charges,,,315.56,,,percent of total billed charges,,,,,,,,,,,,,,,371.25,,,percent of total billed charges,,,197.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,371.25,,,percent of total billed charges,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,371.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,371.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.74,,,percent of total billed charges,,
PHENYLEPHRINE 2.5  OPH 15ML,2500015214,CDM,637,RC,1747820115,NDC,,,,,,outpatient,facility,15,UN,371.25,371.25,29.7,548.68,,263.25,,,percent of total billed charges,,,90.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,371.25,,,percent of total billed charges,,,232.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,260.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,260.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,371.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,135.88,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,371.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,371.25,,,fee schedule,,,371.25,,,percent of total billed charges,,,,,,,,,371.25,,,percent of total billed charges,,,227.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.52,,,percent of total billed charges,,,,,,,,,,,,,,,200.48,,,percent of total billed charges,,,193.05,,,percent of total billed charges,,,204.19,,,percent of total billed charges,,,,,,,,,219.04,,,percent of total billed charges,,,548.68,,,per diem,,,371.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,371.25,,,percent of total billed charges,,,315.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,197.17,,,percent of total billed charges,,,371.25,,,percent of total billed charges,,,371.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.45,,,percent of total billed charges,,,300.42,,,percent of total billed charges,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,137.36,,,percent of total billed charges,,,137.36,,,percent of total billed charges,,,,,,,,,371.25,,,percent of total billed charges,,,371.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,371.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.7,,,percent of total billed charges,,,371.25,,,percent of total billed charges,,,,,,,,,,,,,,,371.25,,,percent of total billed charges,,,371.25,,,percent of total billed charges,,,,,,,,,345.34,,,percent of total billed charges,,,,,,,,,,,,,,,345.34,,,percent of total billed charges,,,345.34,,,percent of total billed charges,,,345.34,,,percent of total billed charges,,,278.44,,,percent of total billed charges,,,371.25,,,percent of total billed charges,,,371.25,,,percent of total billed charges,,,371.25,,,percent of total billed charges,,,,,,,,,260.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,218.74,,,percent of total billed charges,,
PHENYLEPHRINE 2.5  OPH 15ML,2500015214,CDM,637,RC,1747820115,NDC,999,EAPG,,,,outpatient,facility,15,UN,371.25,371.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYTOIN 50 MG CHEW TAB,2500015240,CDM,637,RC,6068715625,NDC,,,,,,inpatient,facility,50,UN,5.94,5.94,0.48,5.94,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,5.94,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,5.05,,,percent of total billed charges,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,3.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,
PHENYTOIN 50 MG CHEW TAB,2500015240,CDM,637,RC,6068715625,NDC,,,,,,outpatient,facility,50,UN,5.94,5.94,0.48,548.68,,4.21,,,percent of total billed charges,,,1.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.94,,,percent of total billed charges,,,3.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.17,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.94,,,fee schedule,,,5.94,,,percent of total billed charges,,,,,,,,,5.94,,,percent of total billed charges,,,3.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.23,,,percent of total billed charges,,,,,,,,,,,,,,,3.21,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,3.27,,,percent of total billed charges,,,,,,,,,3.5,,,percent of total billed charges,,,548.68,,,per diem,,,5.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.94,,,percent of total billed charges,,,5.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.15,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,,4.81,,,percent of total billed charges,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,,,,,,,2.2,,,percent of total billed charges,,,2.2,,,percent of total billed charges,,,,,,,,,5.94,,,percent of total billed charges,,,5.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.48,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,,,,,,,5.53,,,percent of total billed charges,,,,,,,,,,,,,,,5.53,,,percent of total billed charges,,,5.53,,,percent of total billed charges,,,5.53,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.5,,,percent of total billed charges,,
PHENYTOIN 50 MG CHEW TAB,2500015240,CDM,637,RC,6068715625,NDC,999,EAPG,,,,outpatient,facility,50,UN,5.94,5.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYTOIN 100 MG CAP,2500015241,CDM,637,RC,904618761,NDC,,,,,,inpatient,facility,100,UN,2.01,2.01,0.16,2.01,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
PHENYTOIN 100 MG CAP,2500015241,CDM,637,RC,904618761,NDC,,,,,,outpatient,facility,100,UN,2.01,2.01,0.16,548.68,,1.43,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.01,,,percent of total billed charges,,,1.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.01,,,fee schedule,,,2.01,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,1.19,,,percent of total billed charges,,,548.68,,,per diem,,,2.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.01,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
PHENYTOIN 100 MG CAP,2500015241,CDM,637,RC,904618761,NDC,999,EAPG,,,,outpatient,facility,100,UN,2.01,2.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYTOIN 30 MG CAP,2500015242,CDM,637,RC,71374066,NDC,,,,,,inpatient,facility,30,UN,4.78,4.78,0.38,4.78,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,,,,4.78,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.82,,,percent of total billed charges,,
PHENYTOIN 30 MG CAP,2500015242,CDM,637,RC,71374066,NDC,,,,,,outpatient,facility,30,UN,4.78,4.78,0.38,548.68,,3.39,,,percent of total billed charges,,,1.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.78,,,percent of total billed charges,,,3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.75,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.78,,,fee schedule,,,4.78,,,percent of total billed charges,,,,,,,,,4.78,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.41,,,percent of total billed charges,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,2.49,,,percent of total billed charges,,,2.63,,,percent of total billed charges,,,,,,,,,2.82,,,percent of total billed charges,,,548.68,,,per diem,,,4.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.78,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,4.78,,,percent of total billed charges,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,,,,,,,1.77,,,percent of total billed charges,,,1.77,,,percent of total billed charges,,,,,,,,,4.78,,,percent of total billed charges,,,4.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.38,,,percent of total billed charges,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,4.78,,,percent of total billed charges,,,,,,,,,4.45,,,percent of total billed charges,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,3.58,,,percent of total billed charges,,,4.78,,,percent of total billed charges,,,4.78,,,percent of total billed charges,,,4.78,,,percent of total billed charges,,,,,,,,,3.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.82,,,percent of total billed charges,,
PHENYTOIN 30 MG CAP,2500015242,CDM,637,RC,71374066,NDC,999,EAPG,,,,outpatient,facility,30,UN,4.78,4.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENYTOIN 100 MG/4 ML UDC,2500015245,CDM,637,RC,6668903650,NDC,,,,,,inpatient,facility,4,ML,28.51,28.51,2.28,28.51,,,,,,,,,,,,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.51,,,percent of total billed charges,,,,,,,,,28.51,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.11,,,percent of total billed charges,,,,,,,,,,,,,,,28.51,,,percent of total billed charges,,,24.23,,,percent of total billed charges,,,,,,,,,,,,,,,28.51,,,percent of total billed charges,,,15.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.8,,,percent of total billed charges,,
PHENYTOIN 100 MG/4 ML UDC,2500015245,CDM,637,RC,6668903650,NDC,,,,,,outpatient,facility,4,ML,28.51,28.51,2.28,548.68,,20.22,,,percent of total billed charges,,,6.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,28.51,,,percent of total billed charges,,,17.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,20.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,20.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.43,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,28.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,28.51,,,fee schedule,,,28.51,,,percent of total billed charges,,,,,,,,,28.51,,,percent of total billed charges,,,17.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.31,,,percent of total billed charges,,,,,,,,,,,,,,,15.4,,,percent of total billed charges,,,14.83,,,percent of total billed charges,,,15.68,,,percent of total billed charges,,,,,,,,,16.82,,,percent of total billed charges,,,548.68,,,per diem,,,28.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,28.51,,,percent of total billed charges,,,24.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.14,,,percent of total billed charges,,,28.51,,,percent of total billed charges,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.23,,,percent of total billed charges,,,23.07,,,percent of total billed charges,,,,,,,,,,,,,,,11.4,,,percent of total billed charges,,,,,,,,,10.55,,,percent of total billed charges,,,10.55,,,percent of total billed charges,,,,,,,,,28.51,,,percent of total billed charges,,,28.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.28,,,percent of total billed charges,,,28.51,,,percent of total billed charges,,,,,,,,,,,,,,,28.51,,,percent of total billed charges,,,28.51,,,percent of total billed charges,,,,,,,,,26.52,,,percent of total billed charges,,,,,,,,,,,,,,,26.52,,,percent of total billed charges,,,26.52,,,percent of total billed charges,,,26.52,,,percent of total billed charges,,,21.38,,,percent of total billed charges,,,28.51,,,percent of total billed charges,,,28.51,,,percent of total billed charges,,,28.51,,,percent of total billed charges,,,,,,,,,19.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.26,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,16.8,,,percent of total billed charges,,
PHENYTOIN 100 MG/4 ML UDC,2500015245,CDM,637,RC,6668903650,NDC,999,EAPG,,,,outpatient,facility,4,ML,28.51,28.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHYTONADIONE 5 MG TAB,2500015260,CDM,637,RC,409915801,NDC,,,,,,inpatient,facility,5,UN,221.07,221.07,17.69,221.07,,,,,,,,,,,,,,221.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.07,,,percent of total billed charges,,,,,,,,,221.07,,,percent of total billed charges,,,112.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.64,,,percent of total billed charges,,,,,,,,,,,,,,,221.07,,,percent of total billed charges,,,187.91,,,percent of total billed charges,,,,,,,,,,,,,,,221.07,,,percent of total billed charges,,,117.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,221.07,,,percent of total billed charges,,,,,,,,,,,,,,,17.69,,,percent of total billed charges,,,221.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,221.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.25,,,percent of total billed charges,,
PHYTONADIONE 5 MG TAB,2500015260,CDM,637,RC,409915801,NDC,,,,,,outpatient,facility,5,UN,221.07,221.07,17.69,548.68,,156.76,,,percent of total billed charges,,,53.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,221.07,,,percent of total billed charges,,,138.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,155.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,155.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,221.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,80.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,221.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,221.07,,,fee schedule,,,221.07,,,percent of total billed charges,,,,,,,,,221.07,,,percent of total billed charges,,,135.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.51,,,percent of total billed charges,,,,,,,,,,,,,,,119.38,,,percent of total billed charges,,,114.96,,,percent of total billed charges,,,121.59,,,percent of total billed charges,,,,,,,,,130.43,,,percent of total billed charges,,,548.68,,,per diem,,,221.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,221.07,,,percent of total billed charges,,,187.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,117.41,,,percent of total billed charges,,,221.07,,,percent of total billed charges,,,221.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.13,,,percent of total billed charges,,,178.89,,,percent of total billed charges,,,,,,,,,,,,,,,88.43,,,percent of total billed charges,,,,,,,,,81.8,,,percent of total billed charges,,,81.8,,,percent of total billed charges,,,,,,,,,221.07,,,percent of total billed charges,,,221.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,221.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.69,,,percent of total billed charges,,,221.07,,,percent of total billed charges,,,,,,,,,,,,,,,221.07,,,percent of total billed charges,,,221.07,,,percent of total billed charges,,,,,,,,,205.64,,,percent of total billed charges,,,,,,,,,,,,,,,205.64,,,percent of total billed charges,,,205.64,,,percent of total billed charges,,,205.64,,,percent of total billed charges,,,165.8,,,percent of total billed charges,,,221.07,,,percent of total billed charges,,,221.07,,,percent of total billed charges,,,221.07,,,percent of total billed charges,,,,,,,,,154.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,130.25,,,percent of total billed charges,,
PHYTONADIONE 5 MG TAB,2500015260,CDM,637,RC,409915801,NDC,999,EAPG,,,,outpatient,facility,5,UN,221.07,221.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PILOCARPINE HCL 1  OPH 15ML,2500015273,CDM,637,RC,6131420315,NDC,,,,,,inpatient,facility,15,UN,325.25,325.25,26.02,325.25,,,,,,,,,,,,,,325.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.25,,,percent of total billed charges,,,,,,,,,325.25,,,percent of total billed charges,,,166.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,277.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.15,,,percent of total billed charges,,,,,,,,,,,,,,,325.25,,,percent of total billed charges,,,276.46,,,percent of total billed charges,,,,,,,,,,,,,,,325.25,,,percent of total billed charges,,,172.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,325.25,,,percent of total billed charges,,,,,,,,,,,,,,,26.02,,,percent of total billed charges,,,325.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,325.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.64,,,percent of total billed charges,,
PILOCARPINE HCL 1  OPH 15ML,2500015273,CDM,637,RC,6131420315,NDC,,,,,,outpatient,facility,15,UN,325.25,325.25,26.02,548.68,,230.63,,,percent of total billed charges,,,79.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,325.25,,,percent of total billed charges,,,203.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,228.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,228.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,325.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,119.04,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,325.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,325.25,,,fee schedule,,,325.25,,,percent of total billed charges,,,,,,,,,325.25,,,percent of total billed charges,,,199.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.74,,,percent of total billed charges,,,,,,,,,,,,,,,175.64,,,percent of total billed charges,,,169.13,,,percent of total billed charges,,,178.89,,,percent of total billed charges,,,,,,,,,191.9,,,percent of total billed charges,,,548.68,,,per diem,,,325.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,325.25,,,percent of total billed charges,,,276.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,172.74,,,percent of total billed charges,,,325.25,,,percent of total billed charges,,,325.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.41,,,percent of total billed charges,,,263.19,,,percent of total billed charges,,,,,,,,,,,,,,,130.1,,,percent of total billed charges,,,,,,,,,120.34,,,percent of total billed charges,,,120.34,,,percent of total billed charges,,,,,,,,,325.25,,,percent of total billed charges,,,325.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,325.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.02,,,percent of total billed charges,,,325.25,,,percent of total billed charges,,,,,,,,,,,,,,,325.25,,,percent of total billed charges,,,325.25,,,percent of total billed charges,,,,,,,,,302.55,,,percent of total billed charges,,,,,,,,,,,,,,,302.55,,,percent of total billed charges,,,302.55,,,percent of total billed charges,,,302.55,,,percent of total billed charges,,,243.94,,,percent of total billed charges,,,325.25,,,percent of total billed charges,,,325.25,,,percent of total billed charges,,,325.25,,,percent of total billed charges,,,,,,,,,228.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,191.64,,,percent of total billed charges,,
PILOCARPINE HCL 1  OPH 15ML,2500015273,CDM,637,RC,6131420315,NDC,999,EAPG,,,,outpatient,facility,15,UN,325.25,325.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PILOCARPINE HCL 2  OPH 15ML,2500015275,CDM,637,RC,6131420415,NDC,,,,,,inpatient,facility,15,UN,332.67,332.67,26.61,332.67,,,,,,,,,,,,,,332.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.67,,,percent of total billed charges,,,,,,,,,332.67,,,percent of total billed charges,,,169.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.6,,,percent of total billed charges,,,,,,,,,,,,,,,332.67,,,percent of total billed charges,,,282.77,,,percent of total billed charges,,,,,,,,,,,,,,,332.67,,,percent of total billed charges,,,176.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,332.67,,,percent of total billed charges,,,,,,,,,,,,,,,26.61,,,percent of total billed charges,,,332.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,332.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.01,,,percent of total billed charges,,
PILOCARPINE HCL 2  OPH 15ML,2500015275,CDM,637,RC,6131420415,NDC,,,,,,outpatient,facility,15,UN,332.67,332.67,26.61,548.68,,235.9,,,percent of total billed charges,,,81.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,332.67,,,percent of total billed charges,,,208.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,233.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,233.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,332.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,121.76,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,332.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,332.67,,,fee schedule,,,332.67,,,percent of total billed charges,,,,,,,,,332.67,,,percent of total billed charges,,,203.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.03,,,percent of total billed charges,,,,,,,,,,,,,,,179.64,,,percent of total billed charges,,,172.99,,,percent of total billed charges,,,182.97,,,percent of total billed charges,,,,,,,,,196.28,,,percent of total billed charges,,,548.68,,,per diem,,,332.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,332.67,,,percent of total billed charges,,,282.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,176.68,,,percent of total billed charges,,,332.67,,,percent of total billed charges,,,332.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.42,,,percent of total billed charges,,,269.2,,,percent of total billed charges,,,,,,,,,,,,,,,133.07,,,percent of total billed charges,,,,,,,,,123.09,,,percent of total billed charges,,,123.09,,,percent of total billed charges,,,,,,,,,332.67,,,percent of total billed charges,,,332.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,332.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.61,,,percent of total billed charges,,,332.67,,,percent of total billed charges,,,,,,,,,,,,,,,332.67,,,percent of total billed charges,,,332.67,,,percent of total billed charges,,,,,,,,,309.45,,,percent of total billed charges,,,,,,,,,,,,,,,309.45,,,percent of total billed charges,,,309.45,,,percent of total billed charges,,,309.45,,,percent of total billed charges,,,249.5,,,percent of total billed charges,,,332.67,,,percent of total billed charges,,,332.67,,,percent of total billed charges,,,332.67,,,percent of total billed charges,,,,,,,,,233.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,196.01,,,percent of total billed charges,,
PILOCARPINE HCL 2  OPH 15ML,2500015275,CDM,637,RC,6131420415,NDC,999,EAPG,,,,outpatient,facility,15,UN,332.67,332.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PILOCARPINE HCL 5 MG TAB,2500015289,CDM,637,RC,574079201,NDC,,,,,,inpatient,facility,5,UN,1.35,1.35,0.11,1.35,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,
PILOCARPINE HCL 5 MG TAB,2500015289,CDM,637,RC,574079201,NDC,,,,,,outpatient,facility,5,UN,1.35,1.35,0.11,548.68,,0.96,,,percent of total billed charges,,,0.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.35,,,percent of total billed charges,,,0.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.35,,,fee schedule,,,1.35,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,0.8,,,percent of total billed charges,,,548.68,,,per diem,,,1.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.35,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.8,,,percent of total billed charges,,
PILOCARPINE HCL 5 MG TAB,2500015289,CDM,637,RC,574079201,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.35,1.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PIOGLITAZONE HCL 15 MG TAB,2500015310,CDM,637,RC,5723721930,NDC,,,,,,inpatient,facility,15,UN,23.13,23.13,1.85,23.13,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,,,,,,,23.13,,,percent of total billed charges,,,11.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.88,,,percent of total billed charges,,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,19.66,,,percent of total billed charges,,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.63,,,percent of total billed charges,,
PIOGLITAZONE HCL 15 MG TAB,2500015310,CDM,637,RC,5723721930,NDC,,,,,,outpatient,facility,15,UN,23.13,23.13,1.85,548.68,,16.4,,,percent of total billed charges,,,5.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,23.13,,,percent of total billed charges,,,14.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,16.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,16.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.47,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,23.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,23.13,,,fee schedule,,,23.13,,,percent of total billed charges,,,,,,,,,23.13,,,percent of total billed charges,,,14.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.48,,,percent of total billed charges,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,12.03,,,percent of total billed charges,,,12.72,,,percent of total billed charges,,,,,,,,,13.65,,,percent of total billed charges,,,548.68,,,per diem,,,23.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,23.13,,,percent of total billed charges,,,19.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.6,,,percent of total billed charges,,,18.72,,,percent of total billed charges,,,,,,,,,,,,,,,9.25,,,percent of total billed charges,,,,,,,,,8.56,,,percent of total billed charges,,,8.56,,,percent of total billed charges,,,,,,,,,23.13,,,percent of total billed charges,,,23.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.85,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,,,,,,,,,,,,,23.13,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,,,,,,,21.52,,,percent of total billed charges,,,,,,,,,,,,,,,21.52,,,percent of total billed charges,,,21.52,,,percent of total billed charges,,,21.52,,,percent of total billed charges,,,17.35,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,23.13,,,percent of total billed charges,,,,,,,,,16.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.63,,,percent of total billed charges,,
PIOGLITAZONE HCL 15 MG TAB,2500015310,CDM,637,RC,5723721930,NDC,999,EAPG,,,,outpatient,facility,15,UN,23.13,23.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POLIOVIRUS VAC INACTIVAT 0.5ML,2500015371,CDM,636,RC,90713,CPT,4928186010,NDC,,,,inpatient,facility,0.5,UN,131.64,131.64,10.53,131.64,,,,,,,,,,,,,,131.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.64,,,percent of total billed charges,,,,,,,,,131.64,,,percent of total billed charges,,,67.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.98,,,percent of total billed charges,,,,,,,,,,,,,,,131.64,,,percent of total billed charges,,,111.89,,,percent of total billed charges,,,,,,,,,,,,,,,131.64,,,percent of total billed charges,,,69.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,131.64,,,percent of total billed charges,,,,,,,,,,,,,,,10.53,,,percent of total billed charges,,,131.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,131.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.56,,,percent of total billed charges,,
POLIOVIRUS VAC INACTIVAT 0.5ML,2500015371,CDM,636,RC,90713,CPT,4928186010,NDC,,,,outpatient,facility,0.5,UN,131.64,131.64,10.53,548.68,,93.35,,,percent of total billed charges,,,32.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,131.64,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,131.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,48.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,32.08,,,fee schedule,,,131.64,,,fee schedule,,,131.64,,,percent of total billed charges,,,,,,,,,131.64,,,percent of total billed charges,,,80.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,77.67,,,percent of total billed charges,,,548.68,,,per diem,,,131.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,131.64,,,percent of total billed charges,,,111.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.91,,,percent of total billed charges,,,131.64,,,percent of total billed charges,,,131.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.8,,,percent of total billed charges,,,106.52,,,percent of total billed charges,,,,,,,,,,,,,,,52.66,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,131.64,,,percent of total billed charges,,,131.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,131.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.53,,,percent of total billed charges,,,131.64,,,percent of total billed charges,,,,,,,,,,,,,,,131.64,,,percent of total billed charges,,,131.64,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,31.06,,,fee schedule,,,131.64,,,percent of total billed charges,,,131.64,,,percent of total billed charges,,,131.64,,,percent of total billed charges,,,,,,,,,92.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,77.56,,,percent of total billed charges,,
POLIOVIRUS VAC INACTIVAT 0.5ML,2500015371,CDM,636,RC,90713,CPT,4928186010,NDC,414,EAPG,,outpatient,facility,0.5,UN,131.64,131.64,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POLYETHYLENE GLYCOL 238 GM,2500015380,CDM,637,RC,5199196158,NDC,,,,,,inpatient,facility,238,UN,8.51,8.51,0.68,8.51,,,,,,,,,,,,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.51,,,percent of total billed charges,,,,,,,,,8.51,,,percent of total billed charges,,,4.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.11,,,percent of total billed charges,,,,,,,,,,,,,,,8.51,,,percent of total billed charges,,,7.23,,,percent of total billed charges,,,,,,,,,,,,,,,8.51,,,percent of total billed charges,,,4.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,
POLYETHYLENE GLYCOL 238 GM,2500015380,CDM,637,RC,5199196158,NDC,,,,,,outpatient,facility,238,UN,8.51,8.51,0.68,548.68,,6.03,,,percent of total billed charges,,,2.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.51,,,percent of total billed charges,,,5.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.51,,,fee schedule,,,8.51,,,percent of total billed charges,,,,,,,,,8.51,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.06,,,percent of total billed charges,,,,,,,,,,,,,,,4.6,,,percent of total billed charges,,,4.43,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,5.02,,,percent of total billed charges,,,548.68,,,per diem,,,8.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.51,,,percent of total billed charges,,,7.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.52,,,percent of total billed charges,,,8.51,,,percent of total billed charges,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,6.89,,,percent of total billed charges,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,3.15,,,percent of total billed charges,,,3.15,,,percent of total billed charges,,,,,,,,,8.51,,,percent of total billed charges,,,8.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.68,,,percent of total billed charges,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,8.51,,,percent of total billed charges,,,8.51,,,percent of total billed charges,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,6.38,,,percent of total billed charges,,,8.51,,,percent of total billed charges,,,8.51,,,percent of total billed charges,,,8.51,,,percent of total billed charges,,,,,,,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.01,,,percent of total billed charges,,
POLYETHYLENE GLYCOL 238 GM,2500015380,CDM,637,RC,5199196158,NDC,999,EAPG,,,,outpatient,facility,238,UN,8.51,8.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POLYMIN/TRIMETHOPRIM OPH 10ML,2500015392,CDM,637,RC,6075890810,NDC,,,,,,inpatient,facility,10,UN,43.13,43.13,3.45,43.13,,,,,,,,,,,,,,43.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.13,,,percent of total billed charges,,,,,,,,,43.13,,,percent of total billed charges,,,22.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.88,,,percent of total billed charges,,,,,,,,,,,,,,,43.13,,,percent of total billed charges,,,36.66,,,percent of total billed charges,,,,,,,,,,,,,,,43.13,,,percent of total billed charges,,,22.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,43.13,,,percent of total billed charges,,,,,,,,,,,,,,,3.45,,,percent of total billed charges,,,43.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.41,,,percent of total billed charges,,
POLYMIN/TRIMETHOPRIM OPH 10ML,2500015392,CDM,637,RC,6075890810,NDC,,,,,,outpatient,facility,10,UN,43.13,43.13,3.45,548.68,,30.58,,,percent of total billed charges,,,10.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,43.13,,,percent of total billed charges,,,27.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,30.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,30.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,43.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,15.79,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,43.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,43.13,,,fee schedule,,,43.13,,,percent of total billed charges,,,,,,,,,43.13,,,percent of total billed charges,,,26.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.73,,,percent of total billed charges,,,,,,,,,,,,,,,23.29,,,percent of total billed charges,,,22.43,,,percent of total billed charges,,,23.72,,,percent of total billed charges,,,,,,,,,25.45,,,percent of total billed charges,,,548.68,,,per diem,,,43.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,43.13,,,percent of total billed charges,,,36.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.91,,,percent of total billed charges,,,43.13,,,percent of total billed charges,,,43.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.9,,,percent of total billed charges,,,,,,,,,,,,,,,17.25,,,percent of total billed charges,,,,,,,,,15.96,,,percent of total billed charges,,,15.96,,,percent of total billed charges,,,,,,,,,43.13,,,percent of total billed charges,,,43.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.45,,,percent of total billed charges,,,43.13,,,percent of total billed charges,,,,,,,,,,,,,,,43.13,,,percent of total billed charges,,,43.13,,,percent of total billed charges,,,,,,,,,40.12,,,percent of total billed charges,,,,,,,,,,,,,,,40.12,,,percent of total billed charges,,,40.12,,,percent of total billed charges,,,40.12,,,percent of total billed charges,,,32.35,,,percent of total billed charges,,,43.13,,,percent of total billed charges,,,43.13,,,percent of total billed charges,,,43.13,,,percent of total billed charges,,,,,,,,,30.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,25.41,,,percent of total billed charges,,
POLYMIN/TRIMETHOPRIM OPH 10ML,2500015392,CDM,637,RC,6075890810,NDC,999,EAPG,,,,outpatient,facility,10,UN,43.13,43.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM CL PWD 20 MEQ PACK,2500015474,CDM,637,RC,6923816173,NDC,,,,,,inpatient,facility,20,UN,35.44,35.44,2.84,35.44,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,,,,,,,35.44,,,percent of total billed charges,,,18.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.26,,,percent of total billed charges,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,30.12,,,percent of total billed charges,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,18.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,2.84,,,percent of total billed charges,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.88,,,percent of total billed charges,,
POTASSIUM CL PWD 20 MEQ PACK,2500015474,CDM,637,RC,6923816173,NDC,,,,,,outpatient,facility,20,UN,35.44,35.44,2.84,548.68,,25.13,,,percent of total billed charges,,,8.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,35.44,,,percent of total billed charges,,,22.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,24.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,24.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.97,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,35.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,35.44,,,fee schedule,,,35.44,,,percent of total billed charges,,,,,,,,,35.44,,,percent of total billed charges,,,21.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.25,,,percent of total billed charges,,,,,,,,,,,,,,,19.14,,,percent of total billed charges,,,18.43,,,percent of total billed charges,,,19.49,,,percent of total billed charges,,,,,,,,,20.91,,,percent of total billed charges,,,548.68,,,per diem,,,35.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,35.44,,,percent of total billed charges,,,30.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.82,,,percent of total billed charges,,,35.44,,,percent of total billed charges,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.68,,,percent of total billed charges,,,,,,,,,,,,,,,14.18,,,percent of total billed charges,,,,,,,,,13.11,,,percent of total billed charges,,,13.11,,,percent of total billed charges,,,,,,,,,35.44,,,percent of total billed charges,,,35.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.84,,,percent of total billed charges,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,35.44,,,percent of total billed charges,,,,,,,,,32.97,,,percent of total billed charges,,,,,,,,,,,,,,,32.97,,,percent of total billed charges,,,32.97,,,percent of total billed charges,,,32.97,,,percent of total billed charges,,,26.58,,,percent of total billed charges,,,35.44,,,percent of total billed charges,,,35.44,,,percent of total billed charges,,,35.44,,,percent of total billed charges,,,,,,,,,24.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,20.88,,,percent of total billed charges,,
POTASSIUM CL PWD 20 MEQ PACK,2500015474,CDM,637,RC,6923816173,NDC,999,EAPG,,,,outpatient,facility,20,UN,35.44,35.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM CITRATE 5 MEQ TAB,2500015480,CDM,637,RC,4254340601,NDC,,,,,,inpatient,facility,5,UN,5.77,5.77,0.46,5.77,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,5.77,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,4.9,,,percent of total billed charges,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,3.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,
POTASSIUM CITRATE 5 MEQ TAB,2500015480,CDM,637,RC,4254340601,NDC,,,,,,outpatient,facility,5,UN,5.77,5.77,0.46,548.68,,4.09,,,percent of total billed charges,,,1.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.77,,,percent of total billed charges,,,3.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.77,,,fee schedule,,,5.77,,,percent of total billed charges,,,,,,,,,5.77,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.11,,,percent of total billed charges,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,3.4,,,percent of total billed charges,,,548.68,,,per diem,,,5.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.77,,,percent of total billed charges,,,4.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.67,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,2.13,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,,,,,,,5.77,,,percent of total billed charges,,,5.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,,,,,,,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,5.37,,,percent of total billed charges,,,,,,,,,,,,,,,5.37,,,percent of total billed charges,,,5.37,,,percent of total billed charges,,,5.37,,,percent of total billed charges,,,4.33,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,4.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.4,,,percent of total billed charges,,
POTASSIUM CITRATE 5 MEQ TAB,2500015480,CDM,637,RC,4254340601,NDC,999,EAPG,,,,outpatient,facility,5,UN,5.77,5.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM/SOD PHOS PWD 1.25GM,2500015510,CDM,637,RC,6025800601,NDC,,,,,,inpatient,facility,1.25,UN,1.78,1.78,0.14,1.78,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,1.78,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,
POTASSIUM/SOD PHOS PWD 1.25GM,2500015510,CDM,637,RC,6025800601,NDC,,,,,,outpatient,facility,1.25,UN,1.78,1.78,0.14,548.68,,1.26,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.78,,,percent of total billed charges,,,1.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.78,,,fee schedule,,,1.78,,,percent of total billed charges,,,,,,,,,1.78,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,1.05,,,percent of total billed charges,,,548.68,,,per diem,,,1.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.78,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,1.78,,,percent of total billed charges,,,1.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.14,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.05,,,percent of total billed charges,,
POTASSIUM/SOD PHOS PWD 1.25GM,2500015510,CDM,637,RC,6025800601,NDC,999,EAPG,,,,outpatient,facility,1.25,UN,1.78,1.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM/SOD PHOS PWD PK,2500015512,CDM,637,RC,6025800601,NDC,,,,,,inpatient,facility,1.5,UN,1.88,1.88,0.15,1.88,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,
POTASSIUM/SOD PHOS PWD PK,2500015512,CDM,637,RC,6025800601,NDC,,,,,,outpatient,facility,1.5,UN,1.88,1.88,0.15,548.68,,1.33,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.88,,,percent of total billed charges,,,1.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.69,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.88,,,fee schedule,,,1.88,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,1.11,,,percent of total billed charges,,,548.68,,,per diem,,,1.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.88,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,0.7,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,1.88,,,percent of total billed charges,,,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.11,,,percent of total billed charges,,
POTASSIUM/SOD PHOS PWD PK,2500015512,CDM,637,RC,6025800601,NDC,999,EAPG,,,,outpatient,facility,1.5,UN,1.88,1.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM/SOD PHOS 250 MG TAB,2500015516,CDM,637,RC,6498010401,NDC,,,,,,inpatient,facility,250,UN,1.68,1.68,0.13,1.68,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,
POTASSIUM/SOD PHOS 250 MG TAB,2500015516,CDM,637,RC,6498010401,NDC,,,,,,outpatient,facility,250,UN,1.68,1.68,0.13,548.68,,1.19,,,percent of total billed charges,,,0.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.68,,,percent of total billed charges,,,1.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.68,,,fee schedule,,,1.68,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,548.68,,,per diem,,,1.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.68,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.99,,,percent of total billed charges,,
POTASSIUM/SOD PHOS 250 MG TAB,2500015516,CDM,637,RC,6498010401,NDC,999,EAPG,,,,outpatient,facility,250,UN,1.68,1.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM PHOS 3MM/ML 5ML INJ,2500015525,CDM,250,RC,6521905229,NDC,,,,,,inpatient,facility,5,UN,79.13,79.13,6.33,79.13,,,,,,,,,,,,,,79.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.13,,,percent of total billed charges,,,,,,,,,79.13,,,percent of total billed charges,,,40.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.48,,,percent of total billed charges,,,,,,,,,,,,,,,79.13,,,percent of total billed charges,,,67.26,,,percent of total billed charges,,,,,,,,,,,,,,,79.13,,,percent of total billed charges,,,42.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,79.13,,,percent of total billed charges,,,,,,,,,,,,,,,6.33,,,percent of total billed charges,,,79.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.62,,,percent of total billed charges,,
POTASSIUM PHOS 3MM/ML 5ML INJ,2500015525,CDM,250,RC,6521905229,NDC,,,,,,outpatient,facility,5,UN,79.13,79.13,6.33,548.68,,56.11,,,percent of total billed charges,,,19.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,79.13,,,percent of total billed charges,,,49.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,55.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,55.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,79.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,28.96,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,79.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,79.13,,,fee schedule,,,79.13,,,percent of total billed charges,,,,,,,,,79.13,,,percent of total billed charges,,,48.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,46.69,,,percent of total billed charges,,,548.68,,,per diem,,,79.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,79.13,,,percent of total billed charges,,,67.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,42.03,,,percent of total billed charges,,,79.13,,,percent of total billed charges,,,79.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.38,,,percent of total billed charges,,,64.03,,,percent of total billed charges,,,,,,,,,,,,,,,31.65,,,percent of total billed charges,,,,,,,,,31.65,,,percent of total billed charges,,,31.65,,,percent of total billed charges,,,,,,,,,79.13,,,percent of total billed charges,,,79.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,79.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.33,,,percent of total billed charges,,,79.13,,,percent of total billed charges,,,,,,,,,,,,,,,79.13,,,percent of total billed charges,,,79.13,,,percent of total billed charges,,,,,,,,,31.65,,,percent of total billed charges,,,,,,,,,,,,,,,31.65,,,percent of total billed charges,,,31.65,,,percent of total billed charges,,,31.65,,,percent of total billed charges,,,59.35,,,percent of total billed charges,,,79.13,,,percent of total billed charges,,,79.13,,,percent of total billed charges,,,79.13,,,percent of total billed charges,,,,,,,,,55.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,46.62,,,percent of total billed charges,,
POTASSIUM PHOS 3MM/ML 5ML INJ,2500015525,CDM,250,RC,6521905229,NDC,999,EAPG,,,,outpatient,facility,5,UN,79.13,79.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POVIDONE IOD 5  OPH SOLN 30ML,2500015542,CDM,637,RC,65041130,NDC,,,,,,inpatient,facility,30,UN,56.36,56.36,4.51,56.36,,,,,,,,,,,,,,56.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.36,,,percent of total billed charges,,,,,,,,,56.36,,,percent of total billed charges,,,28.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.82,,,percent of total billed charges,,,,,,,,,,,,,,,56.36,,,percent of total billed charges,,,47.91,,,percent of total billed charges,,,,,,,,,,,,,,,56.36,,,percent of total billed charges,,,29.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,56.36,,,percent of total billed charges,,,,,,,,,,,,,,,4.51,,,percent of total billed charges,,,56.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.21,,,percent of total billed charges,,
POVIDONE IOD 5  OPH SOLN 30ML,2500015542,CDM,637,RC,65041130,NDC,,,,,,outpatient,facility,30,UN,56.36,56.36,4.51,548.68,,39.96,,,percent of total billed charges,,,13.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,56.36,,,percent of total billed charges,,,35.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,39.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,39.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,56.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,20.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,56.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,56.36,,,fee schedule,,,56.36,,,percent of total billed charges,,,,,,,,,56.36,,,percent of total billed charges,,,34.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.16,,,percent of total billed charges,,,,,,,,,,,,,,,30.43,,,percent of total billed charges,,,29.31,,,percent of total billed charges,,,31,,,percent of total billed charges,,,,,,,,,33.25,,,percent of total billed charges,,,548.68,,,per diem,,,56.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,56.36,,,percent of total billed charges,,,47.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.93,,,percent of total billed charges,,,56.36,,,percent of total billed charges,,,56.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.02,,,percent of total billed charges,,,45.61,,,percent of total billed charges,,,,,,,,,,,,,,,22.54,,,percent of total billed charges,,,,,,,,,20.85,,,percent of total billed charges,,,20.85,,,percent of total billed charges,,,,,,,,,56.36,,,percent of total billed charges,,,56.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,56.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.51,,,percent of total billed charges,,,56.36,,,percent of total billed charges,,,,,,,,,,,,,,,56.36,,,percent of total billed charges,,,56.36,,,percent of total billed charges,,,,,,,,,52.43,,,percent of total billed charges,,,,,,,,,,,,,,,52.43,,,percent of total billed charges,,,52.43,,,percent of total billed charges,,,52.43,,,percent of total billed charges,,,42.27,,,percent of total billed charges,,,56.36,,,percent of total billed charges,,,56.36,,,percent of total billed charges,,,56.36,,,percent of total billed charges,,,,,,,,,39.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,33.21,,,percent of total billed charges,,
POVIDONE IOD 5  OPH SOLN 30ML,2500015542,CDM,637,RC,65041130,NDC,999,EAPG,,,,outpatient,facility,30,UN,56.36,56.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRAMIPEXOLE 0.125 MG TAB,2500015560,CDM,637,RC,1366809190,NDC,,,,,,inpatient,facility,0.125,UN,9.73,9.73,0.78,9.73,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,9.73,,,percent of total billed charges,,,4.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.84,,,percent of total billed charges,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,8.27,,,percent of total billed charges,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,5.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.73,,,percent of total billed charges,,
PRAMIPEXOLE 0.125 MG TAB,2500015560,CDM,637,RC,1366809190,NDC,,,,,,outpatient,facility,0.125,UN,9.73,9.73,0.78,548.68,,6.9,,,percent of total billed charges,,,2.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.73,,,percent of total billed charges,,,6.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.73,,,fee schedule,,,9.73,,,percent of total billed charges,,,,,,,,,9.73,,,percent of total billed charges,,,5.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,5.25,,,percent of total billed charges,,,5.06,,,percent of total billed charges,,,5.35,,,percent of total billed charges,,,,,,,,,5.74,,,percent of total billed charges,,,548.68,,,per diem,,,9.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.73,,,percent of total billed charges,,,8.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,7.87,,,percent of total billed charges,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,,,,,,,3.6,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,,,,,,,9.73,,,percent of total billed charges,,,9.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.78,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,9.05,,,percent of total billed charges,,,,,,,,,,,,,,,9.05,,,percent of total billed charges,,,9.05,,,percent of total billed charges,,,9.05,,,percent of total billed charges,,,7.3,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,6.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.73,,,percent of total billed charges,,
PRAMIPEXOLE 0.125 MG TAB,2500015560,CDM,637,RC,1366809190,NDC,999,EAPG,,,,outpatient,facility,0.125,UN,9.73,9.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRAMIPEXOLE 0.25 MG TAB,2500015562,CDM,637,RC,1366809290,NDC,,,,,,inpatient,facility,0.25,UN,9.74,9.74,0.78,9.74,,,,,,,,,,,,,,9.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.74,,,percent of total billed charges,,,,,,,,,9.74,,,percent of total billed charges,,,4.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.84,,,percent of total billed charges,,,,,,,,,,,,,,,9.74,,,percent of total billed charges,,,8.28,,,percent of total billed charges,,,,,,,,,,,,,,,9.74,,,percent of total billed charges,,,5.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,9.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,
PRAMIPEXOLE 0.25 MG TAB,2500015562,CDM,637,RC,1366809290,NDC,,,,,,outpatient,facility,0.25,UN,9.74,9.74,0.78,548.68,,6.91,,,percent of total billed charges,,,2.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.74,,,percent of total billed charges,,,6.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.74,,,fee schedule,,,9.74,,,percent of total billed charges,,,,,,,,,9.74,,,percent of total billed charges,,,5.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.94,,,percent of total billed charges,,,,,,,,,,,,,,,5.26,,,percent of total billed charges,,,5.06,,,percent of total billed charges,,,5.36,,,percent of total billed charges,,,,,,,,,5.75,,,percent of total billed charges,,,548.68,,,per diem,,,9.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.74,,,percent of total billed charges,,,8.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,9.74,,,percent of total billed charges,,,9.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,7.88,,,percent of total billed charges,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,,,,,,,3.6,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,,,,,,,9.74,,,percent of total billed charges,,,9.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.78,,,percent of total billed charges,,,9.74,,,percent of total billed charges,,,,,,,,,,,,,,,9.74,,,percent of total billed charges,,,9.74,,,percent of total billed charges,,,,,,,,,9.06,,,percent of total billed charges,,,,,,,,,,,,,,,9.06,,,percent of total billed charges,,,9.06,,,percent of total billed charges,,,9.06,,,percent of total billed charges,,,7.3,,,percent of total billed charges,,,9.74,,,percent of total billed charges,,,9.74,,,percent of total billed charges,,,9.74,,,percent of total billed charges,,,,,,,,,6.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.74,,,percent of total billed charges,,
PRAMIPEXOLE 0.25 MG TAB,2500015562,CDM,637,RC,1366809290,NDC,999,EAPG,,,,outpatient,facility,0.25,UN,9.74,9.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRAMIPEXOLE 0.5 MG TAB,2500015563,CDM,637,RC,1366809390,NDC,,,,,,inpatient,facility,0.5,UN,9.73,9.73,0.78,9.73,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,9.73,,,percent of total billed charges,,,4.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.84,,,percent of total billed charges,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,8.27,,,percent of total billed charges,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,5.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.73,,,percent of total billed charges,,
PRAMIPEXOLE 0.5 MG TAB,2500015563,CDM,637,RC,1366809390,NDC,,,,,,outpatient,facility,0.5,UN,9.73,9.73,0.78,548.68,,6.9,,,percent of total billed charges,,,2.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.73,,,percent of total billed charges,,,6.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.73,,,fee schedule,,,9.73,,,percent of total billed charges,,,,,,,,,9.73,,,percent of total billed charges,,,5.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,5.25,,,percent of total billed charges,,,5.06,,,percent of total billed charges,,,5.35,,,percent of total billed charges,,,,,,,,,5.74,,,percent of total billed charges,,,548.68,,,per diem,,,9.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.73,,,percent of total billed charges,,,8.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.56,,,percent of total billed charges,,,7.87,,,percent of total billed charges,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,,,,,,,,3.6,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,,,,,,,9.73,,,percent of total billed charges,,,9.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.78,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,9.05,,,percent of total billed charges,,,,,,,,,,,,,,,9.05,,,percent of total billed charges,,,9.05,,,percent of total billed charges,,,9.05,,,percent of total billed charges,,,7.3,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,6.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.73,,,percent of total billed charges,,
PRAMIPEXOLE 0.5 MG TAB,2500015563,CDM,637,RC,1366809390,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,9.73,9.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRAMOXINE HCL 1  OINT 30 GM,2500015571,CDM,637,RC,1191707029,NDC,,,,,,inpatient,facility,30,UN,10.26,10.26,0.82,10.26,,,,,,,,,,,,,,10.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.26,,,percent of total billed charges,,,,,,,,,10.26,,,percent of total billed charges,,,5.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.16,,,percent of total billed charges,,,,,,,,,,,,,,,10.26,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,10.26,,,percent of total billed charges,,,5.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.26,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.05,,,percent of total billed charges,,
PRAMOXINE HCL 1  OINT 30 GM,2500015571,CDM,637,RC,1191707029,NDC,,,,,,outpatient,facility,30,UN,10.26,10.26,0.82,548.68,,7.28,,,percent of total billed charges,,,2.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.26,,,percent of total billed charges,,,6.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.76,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.26,,,fee schedule,,,10.26,,,percent of total billed charges,,,,,,,,,10.26,,,percent of total billed charges,,,6.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.31,,,percent of total billed charges,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,,5.34,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,,,,,,,6.05,,,percent of total billed charges,,,548.68,,,per diem,,,10.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.26,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.45,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.92,,,percent of total billed charges,,,8.3,,,percent of total billed charges,,,,,,,,,,,,,,,4.1,,,percent of total billed charges,,,,,,,,,3.8,,,percent of total billed charges,,,3.8,,,percent of total billed charges,,,,,,,,,10.26,,,percent of total billed charges,,,10.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.82,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,,,,,,,,,,,,,10.26,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,,,,,,,9.54,,,percent of total billed charges,,,,,,,,,,,,,,,9.54,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,7.7,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,,,,,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.05,,,percent of total billed charges,,
PRAMOXINE HCL 1  OINT 30 GM,2500015571,CDM,637,RC,1191707029,NDC,999,EAPG,,,,outpatient,facility,30,UN,10.26,10.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRAVASTATIN SOD 10 MG TAB,2500015580,CDM,637,RC,904589161,NDC,,,,,,inpatient,facility,10,UN,1.28,1.28,0.1,1.28,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,1.28,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,
PRAVASTATIN SOD 10 MG TAB,2500015580,CDM,637,RC,904589161,NDC,,,,,,outpatient,facility,10,UN,1.28,1.28,0.1,548.68,,0.91,,,percent of total billed charges,,,0.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.28,,,percent of total billed charges,,,0.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.47,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.28,,,fee schedule,,,1.28,,,percent of total billed charges,,,,,,,,,1.28,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,0.76,,,percent of total billed charges,,,548.68,,,per diem,,,1.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.28,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,,,,0.47,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,,,,,,,1.28,,,percent of total billed charges,,,1.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,0.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.75,,,percent of total billed charges,,
PRAVASTATIN SOD 10 MG TAB,2500015580,CDM,637,RC,904589161,NDC,999,EAPG,,,,outpatient,facility,10,UN,1.28,1.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRAZOSIN HCL 1 MG CAP,2500015600,CDM,637,RC,5976253101,NDC,,,,,,inpatient,facility,1,UN,2.97,2.97,0.24,2.97,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,
PRAZOSIN HCL 1 MG CAP,2500015600,CDM,637,RC,5976253101,NDC,,,,,,outpatient,facility,1,UN,2.97,2.97,0.24,548.68,,2.11,,,percent of total billed charges,,,0.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.97,,,percent of total billed charges,,,1.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.09,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.97,,,fee schedule,,,2.97,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,548.68,,,per diem,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.97,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,2.76,,,percent of total billed charges,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.75,,,percent of total billed charges,,
PRAZOSIN HCL 1 MG CAP,2500015600,CDM,637,RC,5976253101,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.97,2.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRAZOSIN HCL 2 MG CAP,2500015602,CDM,637,RC,5976253201,NDC,,,,,,inpatient,facility,2,UN,4.19,4.19,0.34,4.19,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,4.19,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,
PRAZOSIN HCL 2 MG CAP,2500015602,CDM,637,RC,5976253201,NDC,,,,,,outpatient,facility,2,UN,4.19,4.19,0.34,548.68,,2.97,,,percent of total billed charges,,,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.19,,,percent of total billed charges,,,2.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.53,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.19,,,fee schedule,,,4.19,,,percent of total billed charges,,,,,,,,,4.19,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.99,,,percent of total billed charges,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,,,,,,,2.47,,,percent of total billed charges,,,548.68,,,per diem,,,4.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.19,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.83,,,percent of total billed charges,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,4.19,,,percent of total billed charges,,,4.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.34,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,,,,,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,3.9,,,percent of total billed charges,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,3.9,,,percent of total billed charges,,,3.9,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.47,,,percent of total billed charges,,
PRAZOSIN HCL 2 MG CAP,2500015602,CDM,637,RC,5976253201,NDC,999,EAPG,,,,outpatient,facility,2,UN,4.19,4.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRAZOSIN HCL 5 MG CAP,2500015605,CDM,637,RC,5976253501,NDC,,,,,,inpatient,facility,5,UN,7.19,7.19,0.58,7.19,,,,,,,,,,,,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.19,,,percent of total billed charges,,,,,,,,,7.19,,,percent of total billed charges,,,3.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.31,,,percent of total billed charges,,,,,,,,,,,,,,,7.19,,,percent of total billed charges,,,6.11,,,percent of total billed charges,,,,,,,,,,,,,,,7.19,,,percent of total billed charges,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.24,,,percent of total billed charges,,
PRAZOSIN HCL 5 MG CAP,2500015605,CDM,637,RC,5976253501,NDC,,,,,,outpatient,facility,5,UN,7.19,7.19,0.58,548.68,,5.1,,,percent of total billed charges,,,1.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.19,,,percent of total billed charges,,,4.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.19,,,fee schedule,,,7.19,,,percent of total billed charges,,,,,,,,,7.19,,,percent of total billed charges,,,4.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,,,,,,,,,,,,,3.88,,,percent of total billed charges,,,3.74,,,percent of total billed charges,,,3.95,,,percent of total billed charges,,,,,,,,,4.24,,,percent of total billed charges,,,548.68,,,per diem,,,7.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.19,,,percent of total billed charges,,,6.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.82,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.85,,,percent of total billed charges,,,5.82,,,percent of total billed charges,,,,,,,,,,,,,,,2.88,,,percent of total billed charges,,,,,,,,,2.66,,,percent of total billed charges,,,2.66,,,percent of total billed charges,,,,,,,,,7.19,,,percent of total billed charges,,,7.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.58,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,,,,,,,,,,,,,7.19,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,,,,,,,6.69,,,percent of total billed charges,,,,,,,,,,,,,,,6.69,,,percent of total billed charges,,,6.69,,,percent of total billed charges,,,6.69,,,percent of total billed charges,,,5.39,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,7.19,,,percent of total billed charges,,,,,,,,,5.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.24,,,percent of total billed charges,,
PRAZOSIN HCL 5 MG CAP,2500015605,CDM,637,RC,5976253501,NDC,999,EAPG,,,,outpatient,facility,5,UN,7.19,7.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREDNISOLONE AC 1  OP 5 ML,2500015617,CDM,637,RC,6131463705,NDC,,,,,,inpatient,facility,5,UN,182.56,182.56,14.6,182.56,,,,,,,,,,,,,,182.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.56,,,percent of total billed charges,,,,,,,,,182.56,,,percent of total billed charges,,,93.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.54,,,percent of total billed charges,,,,,,,,,,,,,,,182.56,,,percent of total billed charges,,,155.18,,,percent of total billed charges,,,,,,,,,,,,,,,182.56,,,percent of total billed charges,,,96.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,182.56,,,percent of total billed charges,,,,,,,,,,,,,,,14.6,,,percent of total billed charges,,,182.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,182.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.56,,,percent of total billed charges,,
PREDNISOLONE AC 1  OP 5 ML,2500015617,CDM,637,RC,6131463705,NDC,,,,,,outpatient,facility,5,UN,182.56,182.56,14.6,548.68,,129.45,,,percent of total billed charges,,,44.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,182.56,,,percent of total billed charges,,,114.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,128.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,128.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,182.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,66.82,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,182.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,182.56,,,fee schedule,,,182.56,,,percent of total billed charges,,,,,,,,,182.56,,,percent of total billed charges,,,111.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.07,,,percent of total billed charges,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,94.93,,,percent of total billed charges,,,100.41,,,percent of total billed charges,,,,,,,,,107.71,,,percent of total billed charges,,,548.68,,,per diem,,,182.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,182.56,,,percent of total billed charges,,,155.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,96.96,,,percent of total billed charges,,,182.56,,,percent of total billed charges,,,182.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.15,,,percent of total billed charges,,,147.73,,,percent of total billed charges,,,,,,,,,,,,,,,73.02,,,percent of total billed charges,,,,,,,,,67.55,,,percent of total billed charges,,,67.55,,,percent of total billed charges,,,,,,,,,182.56,,,percent of total billed charges,,,182.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,182.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.6,,,percent of total billed charges,,,182.56,,,percent of total billed charges,,,,,,,,,,,,,,,182.56,,,percent of total billed charges,,,182.56,,,percent of total billed charges,,,,,,,,,169.82,,,percent of total billed charges,,,,,,,,,,,,,,,169.82,,,percent of total billed charges,,,169.82,,,percent of total billed charges,,,169.82,,,percent of total billed charges,,,136.92,,,percent of total billed charges,,,182.56,,,percent of total billed charges,,,182.56,,,percent of total billed charges,,,182.56,,,percent of total billed charges,,,,,,,,,127.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,107.56,,,percent of total billed charges,,
PREDNISOLONE AC 1  OP 5 ML,2500015617,CDM,637,RC,6131463705,NDC,999,EAPG,,,,outpatient,facility,5,UN,182.56,182.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREDNISONE 1 MG TAB,2500015640,CDM,637,RC,J7512,HCPCS,54873925,NDC,,,,inpatient,facility,1,UN,0.92,0.92,0.07,0.92,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,
PREDNISONE 1 MG TAB,2500015640,CDM,637,RC,J7512,HCPCS,54873925,NDC,,,,outpatient,facility,1,UN,0.92,0.92,0.01,548.68,,0.65,,,percent of total billed charges,,,0.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.92,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.34,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.92,,,fee schedule,,,0.92,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,0.54,,,percent of total billed charges,,,548.68,,,per diem,,,0.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.92,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,0.92,,,percent of total billed charges,,,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.01,,,fee schedule,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.54,,,percent of total billed charges,,
PREDNISONE 1 MG TAB,2500015640,CDM,637,RC,J7512,HCPCS,54873925,NDC,496,EAPG,,outpatient,facility,1,UN,0.92,0.92,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREDNISONE 10 MG TAB,2500015641,CDM,637,RC,J7512,HCPCS,904692361,NDC,,,,inpatient,facility,10,UN,0.49,0.49,0.04,0.49,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,
PREDNISONE 10 MG TAB,2500015641,CDM,637,RC,J7512,HCPCS,904692361,NDC,,,,outpatient,facility,10,UN,0.49,0.49,0.01,548.68,,0.35,,,percent of total billed charges,,,0.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.49,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.49,,,fee schedule,,,0.49,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,0.29,,,percent of total billed charges,,,548.68,,,per diem,,,0.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.49,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,0.49,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.01,,,fee schedule,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.29,,,percent of total billed charges,,
PREDNISONE 10 MG TAB,2500015641,CDM,637,RC,J7512,HCPCS,904692361,NDC,496,EAPG,,outpatient,facility,10,UN,0.49,0.49,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREDNISONE 20 MG TAB,2500015642,CDM,637,RC,J7512,HCPCS,54001820,NDC,,,,inpatient,facility,20,UN,0.92,0.92,0.07,0.92,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,
PREDNISONE 20 MG TAB,2500015642,CDM,637,RC,J7512,HCPCS,54001820,NDC,,,,outpatient,facility,20,UN,0.92,0.92,0.01,548.68,,0.65,,,percent of total billed charges,,,0.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.92,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.34,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.92,,,fee schedule,,,0.92,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,0.54,,,percent of total billed charges,,,548.68,,,per diem,,,0.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.92,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,0.92,,,percent of total billed charges,,,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.01,,,fee schedule,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.54,,,percent of total billed charges,,
PREDNISONE 20 MG TAB,2500015642,CDM,637,RC,J7512,HCPCS,54001820,NDC,496,EAPG,,outpatient,facility,20,UN,0.92,0.92,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREDNISONE 5 MG TAB,2500015643,CDM,637,RC,J7512,HCPCS,6068712201,NDC,,,,inpatient,facility,5,UN,0.66,0.66,0.05,0.66,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,
PREDNISONE 5 MG TAB,2500015643,CDM,637,RC,J7512,HCPCS,6068712201,NDC,,,,outpatient,facility,5,UN,0.66,0.66,0.01,548.68,,0.47,,,percent of total billed charges,,,0.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.66,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.24,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.66,,,fee schedule,,,0.66,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,0.39,,,percent of total billed charges,,,548.68,,,per diem,,,0.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.66,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,0.66,,,percent of total billed charges,,,0.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.01,,,fee schedule,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.39,,,percent of total billed charges,,
PREDNISONE 5 MG TAB,2500015643,CDM,637,RC,J7512,HCPCS,6068712201,NDC,496,EAPG,,outpatient,facility,5,UN,0.66,0.66,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRIMIDONE 250 MG TAB,2500015700,CDM,637,RC,5374654501,NDC,,,,,,inpatient,facility,250,UN,3.3,3.3,0.26,3.3,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,3.3,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,
PRIMIDONE 250 MG TAB,2500015700,CDM,637,RC,5374654501,NDC,,,,,,outpatient,facility,250,UN,3.3,3.3,0.26,548.68,,2.34,,,percent of total billed charges,,,0.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.3,,,percent of total billed charges,,,2.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.21,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.3,,,fee schedule,,,3.3,,,percent of total billed charges,,,,,,,,,3.3,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,1.95,,,percent of total billed charges,,,548.68,,,per diem,,,3.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.3,,,percent of total billed charges,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,1.22,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,3.3,,,percent of total billed charges,,,3.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,3.3,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.94,,,percent of total billed charges,,
PRIMIDONE 250 MG TAB,2500015700,CDM,637,RC,5374654501,NDC,999,EAPG,,,,outpatient,facility,250,UN,3.3,3.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRIMIDONE 50 MG TAB,2500015701,CDM,637,RC,6808420201,NDC,,,,,,inpatient,facility,50,UN,3.23,3.23,0.26,3.23,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,
PRIMIDONE 50 MG TAB,2500015701,CDM,637,RC,6808420201,NDC,,,,,,outpatient,facility,50,UN,3.23,3.23,0.26,548.68,,2.29,,,percent of total billed charges,,,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.23,,,percent of total billed charges,,,2.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.23,,,fee schedule,,,3.23,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,1.91,,,percent of total billed charges,,,548.68,,,per diem,,,3.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.23,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,1.2,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,3.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.9,,,percent of total billed charges,,
PRIMIDONE 50 MG TAB,2500015701,CDM,637,RC,6808420201,NDC,999,EAPG,,,,outpatient,facility,50,UN,3.23,3.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROBENECID 500 MG TAB,2500015710,CDM,637,RC,591534701,NDC,,,,,,inpatient,facility,500,UN,3.23,3.23,0.26,3.23,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,
PROBENECID 500 MG TAB,2500015710,CDM,637,RC,591534701,NDC,,,,,,outpatient,facility,500,UN,3.23,3.23,0.26,548.68,,2.29,,,percent of total billed charges,,,0.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.23,,,percent of total billed charges,,,2.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.23,,,fee schedule,,,3.23,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,1.91,,,percent of total billed charges,,,548.68,,,per diem,,,3.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.23,,,percent of total billed charges,,,2.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,1.2,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,3.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.26,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,3,,,percent of total billed charges,,,2.42,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,3.23,,,percent of total billed charges,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.9,,,percent of total billed charges,,
PROBENECID 500 MG TAB,2500015710,CDM,637,RC,591534701,NDC,999,EAPG,,,,outpatient,facility,500,UN,3.23,3.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROCHLORPERAZINE 25 MG SUPP,2500015761,CDM,637,RC,J8498,HCPCS,713013512,NDC,,,,inpatient,facility,25,UN,40.46,40.46,3.24,40.46,,,,,,,,,,,,,,40.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.46,,,percent of total billed charges,,,,,,,,,40.46,,,percent of total billed charges,,,20.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.28,,,percent of total billed charges,,,,,,,,,,,,,,,40.46,,,percent of total billed charges,,,34.39,,,percent of total billed charges,,,,,,,,,,,,,,,40.46,,,percent of total billed charges,,,21.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,40.46,,,percent of total billed charges,,,,,,,,,,,,,,,3.24,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.84,,,percent of total billed charges,,
PROCHLORPERAZINE 25 MG SUPP,2500015761,CDM,637,RC,J8498,HCPCS,713013512,NDC,,,,outpatient,facility,25,UN,40.46,40.46,2.2,548.68,,28.69,,,percent of total billed charges,,,9.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,40.46,,,percent of total billed charges,,,25.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,28.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,28.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,40.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,14.81,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,40.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,40.46,,,fee schedule,,,40.46,,,percent of total billed charges,,,,,,,,,40.46,,,percent of total billed charges,,,24.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.83,,,percent of total billed charges,,,,,,,,,,,,,,,40.46,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,,,,,,,23.87,,,percent of total billed charges,,,548.68,,,per diem,,,40.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,40.46,,,percent of total billed charges,,,34.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.49,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.29,,,percent of total billed charges,,,32.74,,,percent of total billed charges,,,,,,,,,,,,,,,16.18,,,percent of total billed charges,,,,,,,,,7.94,,,fee schedule,,,5.71,,,fee schedule,,,,,,,,,40.46,,,percent of total billed charges,,,40.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.24,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,,,,,,,,,,,,,40.46,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,,,,,,,3.39,,,fee schedule,,,,,,,,,,,,,,,2.94,,,fee schedule,,,3.92,,,fee schedule,,,2.2,,,fee schedule,,,30.34,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,40.46,,,percent of total billed charges,,,,,,,,,28.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,23.84,,,percent of total billed charges,,
PROCHLORPERAZINE 25 MG SUPP,2500015761,CDM,637,RC,J8498,HCPCS,713013512,NDC,999,EAPG,,outpatient,facility,25,UN,40.46,40.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROMETHAZINE 12.5 MG SUPP,2500015790,CDM,637,RC,713053612,NDC,,,,,,inpatient,facility,12.5,UN,58.44,58.44,4.68,58.44,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,,,,,,,58.44,,,percent of total billed charges,,,29.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.06,,,percent of total billed charges,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,49.67,,,percent of total billed charges,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,31.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.43,,,percent of total billed charges,,
PROMETHAZINE 12.5 MG SUPP,2500015790,CDM,637,RC,713053612,NDC,,,,,,outpatient,facility,12.5,UN,58.44,58.44,4.68,548.68,,41.44,,,percent of total billed charges,,,14.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,58.44,,,percent of total billed charges,,,36.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,41.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,41.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,21.39,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,58.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,58.44,,,fee schedule,,,58.44,,,percent of total billed charges,,,,,,,,,58.44,,,percent of total billed charges,,,35.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.64,,,percent of total billed charges,,,,,,,,,,,,,,,31.56,,,percent of total billed charges,,,30.39,,,percent of total billed charges,,,32.14,,,percent of total billed charges,,,,,,,,,34.48,,,percent of total billed charges,,,548.68,,,per diem,,,58.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,58.44,,,percent of total billed charges,,,49.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.04,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.42,,,percent of total billed charges,,,47.29,,,percent of total billed charges,,,,,,,,,,,,,,,23.38,,,percent of total billed charges,,,,,,,,,21.62,,,percent of total billed charges,,,21.62,,,percent of total billed charges,,,,,,,,,58.44,,,percent of total billed charges,,,58.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,58.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.68,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,,,,,,,,,,,,,58.44,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,,,,,,,54.36,,,percent of total billed charges,,,,,,,,,,,,,,,54.36,,,percent of total billed charges,,,54.36,,,percent of total billed charges,,,54.36,,,percent of total billed charges,,,43.83,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,58.44,,,percent of total billed charges,,,,,,,,,40.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,34.43,,,percent of total billed charges,,
PROMETHAZINE 12.5 MG SUPP,2500015790,CDM,637,RC,713053612,NDC,999,EAPG,,,,outpatient,facility,12.5,UN,58.44,58.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROMETHAZINE 25 MG TAB,2500015792,CDM,637,RC,Q0169,HCPCS,904646161,NDC,,,,inpatient,facility,25,UN,0.4,0.4,0.03,0.4,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,0.4,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,
PROMETHAZINE 25 MG TAB,2500015792,CDM,637,RC,Q0169,HCPCS,904646161,NDC,,,,outpatient,facility,25,UN,0.4,0.4,0.03,548.68,,0.28,,,percent of total billed charges,,,0.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.4,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.15,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.4,,,fee schedule,,,0.4,,,percent of total billed charges,,,,,,,,,0.4,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,0.24,,,percent of total billed charges,,,548.68,,,per diem,,,0.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.4,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,0.4,,,percent of total billed charges,,,0.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.4,,,fee schedule,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.24,,,percent of total billed charges,,
PROMETHAZINE 25 MG TAB,2500015792,CDM,637,RC,Q0169,HCPCS,904646161,NDC,999,EAPG,,outpatient,facility,25,UN,0.4,0.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROMETHAZINE 6.25 MG/5 ML UDC,2500015794,CDM,636,RC,Q0169,HCPCS,121092716,NDC,,,,inpatient,facility,5,UN,1.68,1.68,0.13,1.68,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,
PROMETHAZINE 6.25 MG/5 ML UDC,2500015794,CDM,636,RC,Q0169,HCPCS,121092716,NDC,,,,outpatient,facility,5,UN,1.68,1.68,0.13,548.68,,1.19,,,percent of total billed charges,,,0.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.68,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.68,,,fee schedule,,,1.68,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,0.99,,,percent of total billed charges,,,548.68,,,per diem,,,1.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.68,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1.68,,,percent of total billed charges,,,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.99,,,percent of total billed charges,,
PROMETHAZINE 6.25 MG/5 ML UDC,2500015794,CDM,636,RC,Q0169,HCPCS,121092716,NDC,999,EAPG,,outpatient,facility,5,UN,1.68,1.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPAFENONE HCL 150 MG TAB,2500015800,CDM,637,RC,5965125601,NDC,,,,,,inpatient,facility,150,UN,5.41,5.41,0.43,5.41,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,5.41,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.25,,,percent of total billed charges,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.19,,,percent of total billed charges,,
PROPAFENONE HCL 150 MG TAB,2500015800,CDM,637,RC,5965125601,NDC,,,,,,outpatient,facility,150,UN,5.41,5.41,0.43,548.68,,3.84,,,percent of total billed charges,,,1.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.41,,,percent of total billed charges,,,3.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.98,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.41,,,fee schedule,,,5.41,,,percent of total billed charges,,,,,,,,,5.41,,,percent of total billed charges,,,3.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,,,,,,,3.19,,,percent of total billed charges,,,548.68,,,per diem,,,5.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.41,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.65,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,5.41,,,percent of total billed charges,,,5.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.43,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,5.03,,,percent of total billed charges,,,5.03,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.19,,,percent of total billed charges,,
PROPAFENONE HCL 150 MG TAB,2500015800,CDM,637,RC,5965125601,NDC,999,EAPG,,,,outpatient,facility,150,UN,5.41,5.41,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPARACAINE 0.5  OPH 15 ML,2500015820,CDM,637,RC,6131401601,NDC,,,,,,inpatient,facility,15,UN,144.8,144.8,11.58,144.8,,,,,,,,,,,,,,144.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.8,,,percent of total billed charges,,,,,,,,,144.8,,,percent of total billed charges,,,73.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,144.8,,,percent of total billed charges,,,123.08,,,percent of total billed charges,,,,,,,,,,,,,,,144.8,,,percent of total billed charges,,,76.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,144.8,,,percent of total billed charges,,,,,,,,,,,,,,,11.58,,,percent of total billed charges,,,144.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,144.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.32,,,percent of total billed charges,,
PROPARACAINE 0.5  OPH 15 ML,2500015820,CDM,637,RC,6131401601,NDC,,,,,,outpatient,facility,15,UN,144.8,144.8,11.58,548.68,,102.68,,,percent of total billed charges,,,35.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,144.8,,,percent of total billed charges,,,90.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,101.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,101.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,144.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,53,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,144.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,144.8,,,fee schedule,,,144.8,,,percent of total billed charges,,,,,,,,,144.8,,,percent of total billed charges,,,88.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.17,,,percent of total billed charges,,,,,,,,,,,,,,,78.19,,,percent of total billed charges,,,75.3,,,percent of total billed charges,,,79.64,,,percent of total billed charges,,,,,,,,,85.43,,,percent of total billed charges,,,548.68,,,per diem,,,144.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,144.8,,,percent of total billed charges,,,123.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,76.9,,,percent of total billed charges,,,144.8,,,percent of total billed charges,,,144.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.68,,,percent of total billed charges,,,117.17,,,percent of total billed charges,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,,,,53.58,,,percent of total billed charges,,,53.58,,,percent of total billed charges,,,,,,,,,144.8,,,percent of total billed charges,,,144.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,144.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.58,,,percent of total billed charges,,,144.8,,,percent of total billed charges,,,,,,,,,,,,,,,144.8,,,percent of total billed charges,,,144.8,,,percent of total billed charges,,,,,,,,,134.69,,,percent of total billed charges,,,,,,,,,,,,,,,134.69,,,percent of total billed charges,,,134.69,,,percent of total billed charges,,,134.69,,,percent of total billed charges,,,108.6,,,percent of total billed charges,,,144.8,,,percent of total billed charges,,,144.8,,,percent of total billed charges,,,144.8,,,percent of total billed charges,,,,,,,,,101.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,85.32,,,percent of total billed charges,,
PROPARACAINE 0.5  OPH 15 ML,2500015820,CDM,637,RC,6131401601,NDC,999,EAPG,,,,outpatient,facility,15,UN,144.8,144.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPOFOL IV 10MG/ML 100 ML INJ,2500015830,CDM,636,RC,J2704,HCPCS,6332326965,NDC,,,,inpatient,facility,100,ML,99,99,7.92,99,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,99,,,percent of total billed charges,,,50.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,84.15,,,percent of total billed charges,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,52.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.33,,,percent of total billed charges,,
PROPOFOL IV 10MG/ML 100 ML INJ,2500015830,CDM,636,RC,J2704,HCPCS,6332326965,NDC,,,,outpatient,facility,100,ML,99,99,0.09,548.68,,70.2,,,percent of total billed charges,,,24.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,99,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,36.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,99,,,fee schedule,,,99,,,percent of total billed charges,,,,,,,,,99,,,percent of total billed charges,,,60.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,58.41,,,percent of total billed charges,,,548.68,,,per diem,,,99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,99,,,percent of total billed charges,,,84.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.58,,,percent of total billed charges,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.79,,,percent of total billed charges,,,80.11,,,percent of total billed charges,,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,99,,,percent of total billed charges,,,99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.92,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.09,,,fee schedule,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,69.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,58.33,,,percent of total billed charges,,
PROPOFOL IV 10MG/ML 100 ML INJ,2500015830,CDM,636,RC,J2704,HCPCS,6332326965,NDC,496,EAPG,,outpatient,facility,100,ML,99,99,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPOFOL IV 10 MG/ML 20 ML AMP,2500015832,CDM,636,RC,J2704,HCPCS,6332326970,NDC,,,,inpatient,facility,20,ML,7.92,7.92,0.63,7.92,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,7.92,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,6.73,,,percent of total billed charges,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.67,,,percent of total billed charges,,
PROPOFOL IV 10 MG/ML 20 ML AMP,2500015832,CDM,636,RC,J2704,HCPCS,6332326970,NDC,,,,outpatient,facility,20,ML,7.92,7.92,0.09,548.68,,5.62,,,percent of total billed charges,,,1.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.92,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.9,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.92,,,fee schedule,,,7.92,,,percent of total billed charges,,,,,,,,,7.92,,,percent of total billed charges,,,4.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,4.67,,,percent of total billed charges,,,548.68,,,per diem,,,7.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.92,,,percent of total billed charges,,,6.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.21,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.34,,,percent of total billed charges,,,6.41,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7.92,,,percent of total billed charges,,,7.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.63,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.09,,,fee schedule,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,,,,,,,5.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.67,,,percent of total billed charges,,
PROPOFOL IV 10 MG/ML 20 ML AMP,2500015832,CDM,636,RC,J2704,HCPCS,6332326970,NDC,496,EAPG,,outpatient,facility,20,ML,7.92,7.92,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPOFOL IV 10 MG/ML 50 ML INJ,2500015833,CDM,636,RC,J2704,HCPCS,409469933,NDC,,,,inpatient,facility,50,ML,35.64,35.64,2.85,35.64,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,35.64,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.38,,,percent of total billed charges,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,30.29,,,percent of total billed charges,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,18.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21,,,percent of total billed charges,,
PROPOFOL IV 10 MG/ML 50 ML INJ,2500015833,CDM,636,RC,J2704,HCPCS,409469933,NDC,,,,outpatient,facility,50,ML,35.64,35.64,0.09,548.68,,25.27,,,percent of total billed charges,,,8.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,35.64,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,13.04,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,35.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,35.64,,,fee schedule,,,35.64,,,percent of total billed charges,,,,,,,,,35.64,,,percent of total billed charges,,,21.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,21.03,,,percent of total billed charges,,,548.68,,,per diem,,,35.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,35.64,,,percent of total billed charges,,,30.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.93,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.04,,,percent of total billed charges,,,28.84,,,percent of total billed charges,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,35.64,,,percent of total billed charges,,,35.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.85,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.09,,,fee schedule,,,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,,,,,,,24.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,21,,,percent of total billed charges,,
PROPOFOL IV 10 MG/ML 50 ML INJ,2500015833,CDM,636,RC,J2704,HCPCS,409469933,NDC,496,EAPG,,outpatient,facility,50,ML,35.64,35.64,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPRANOLOL HCL 10 MG TAB,2500015850,CDM,637,RC,904655061,NDC,,,,,,inpatient,facility,10,UN,0.76,0.76,0.06,0.76,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,0.76,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,
PROPRANOLOL HCL 10 MG TAB,2500015850,CDM,637,RC,904655061,NDC,,,,,,outpatient,facility,10,UN,0.76,0.76,0.06,548.68,,0.54,,,percent of total billed charges,,,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.76,,,percent of total billed charges,,,0.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.28,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.76,,,fee schedule,,,0.76,,,percent of total billed charges,,,,,,,,,0.76,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,0.45,,,percent of total billed charges,,,548.68,,,per diem,,,0.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.76,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,0.28,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,0.76,,,percent of total billed charges,,,0.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.45,,,percent of total billed charges,,
PROPRANOLOL HCL 10 MG TAB,2500015850,CDM,637,RC,904655061,NDC,999,EAPG,,,,outpatient,facility,10,UN,0.76,0.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPRANOLOL HCL 40 MG TAB,2500015852,CDM,637,RC,5026870215,NDC,,,,,,inpatient,facility,40,UN,2.14,2.14,0.17,2.14,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,2.14,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,
PROPRANOLOL HCL 40 MG TAB,2500015852,CDM,637,RC,5026870215,NDC,,,,,,outpatient,facility,40,UN,2.14,2.14,0.17,548.68,,1.52,,,percent of total billed charges,,,0.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.14,,,percent of total billed charges,,,1.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.78,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.14,,,fee schedule,,,2.14,,,percent of total billed charges,,,,,,,,,2.14,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,1.26,,,percent of total billed charges,,,548.68,,,per diem,,,2.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.14,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,2.14,,,percent of total billed charges,,,2.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.26,,,percent of total billed charges,,
PROPRANOLOL HCL 40 MG TAB,2500015852,CDM,637,RC,5026870215,NDC,999,EAPG,,,,outpatient,facility,40,UN,2.14,2.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPRANOLOL LA 60 MG CAP,2500015857,CDM,637,RC,5199181701,NDC,,,,,,inpatient,facility,60,UN,6.8,6.8,0.54,6.8,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,6.8,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.08,,,percent of total billed charges,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,3.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,
PROPRANOLOL LA 60 MG CAP,2500015857,CDM,637,RC,5199181701,NDC,,,,,,outpatient,facility,60,UN,6.8,6.8,0.54,548.68,,4.82,,,percent of total billed charges,,,1.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.8,,,percent of total billed charges,,,4.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.8,,,fee schedule,,,6.8,,,percent of total billed charges,,,,,,,,,6.8,,,percent of total billed charges,,,4.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.84,,,percent of total billed charges,,,,,,,,,,,,,,,3.67,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,3.74,,,percent of total billed charges,,,,,,,,,4.01,,,percent of total billed charges,,,548.68,,,per diem,,,6.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.8,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.61,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,5.5,,,percent of total billed charges,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,,,,,,,,2.52,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,6.8,,,percent of total billed charges,,,6.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.54,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,6.33,,,percent of total billed charges,,,,,,,,,,,,,,,6.33,,,percent of total billed charges,,,6.33,,,percent of total billed charges,,,6.33,,,percent of total billed charges,,,5.1,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.01,,,percent of total billed charges,,
PROPRANOLOL LA 60 MG CAP,2500015857,CDM,637,RC,5199181701,NDC,999,EAPG,,,,outpatient,facility,60,UN,6.8,6.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPRANOLOL LA 80 MG CAP,2500015858,CDM,637,RC,5199181801,NDC,,,,,,inpatient,facility,80,UN,7.95,7.95,0.64,7.95,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,7.95,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,6.76,,,percent of total billed charges,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,
PROPRANOLOL LA 80 MG CAP,2500015858,CDM,637,RC,5199181801,NDC,,,,,,outpatient,facility,80,UN,7.95,7.95,0.64,548.68,,5.64,,,percent of total billed charges,,,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.95,,,percent of total billed charges,,,4.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.95,,,fee schedule,,,7.95,,,percent of total billed charges,,,,,,,,,7.95,,,percent of total billed charges,,,4.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.66,,,percent of total billed charges,,,,,,,,,,,,,,,4.29,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,4.37,,,percent of total billed charges,,,,,,,,,4.69,,,percent of total billed charges,,,548.68,,,per diem,,,7.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.95,,,percent of total billed charges,,,6.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.36,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,3.18,,,percent of total billed charges,,,,,,,,,2.94,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,7.95,,,percent of total billed charges,,,7.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.64,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,7.4,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,5.96,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,5.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.68,,,percent of total billed charges,,
PROPRANOLOL LA 80 MG CAP,2500015858,CDM,637,RC,5199181801,NDC,999,EAPG,,,,outpatient,facility,80,UN,7.95,7.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPYLTHIOURACIL 50 MG TAB,2500015860,CDM,637,RC,480924201,NDC,,,,,,inpatient,facility,50,UN,2.97,2.97,0.24,2.97,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,
PROPYLTHIOURACIL 50 MG TAB,2500015860,CDM,637,RC,480924201,NDC,,,,,,outpatient,facility,50,UN,2.97,2.97,0.24,548.68,,2.11,,,percent of total billed charges,,,0.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.97,,,percent of total billed charges,,,1.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.09,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.97,,,fee schedule,,,2.97,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,548.68,,,per diem,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.97,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,2.76,,,percent of total billed charges,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.75,,,percent of total billed charges,,
PROPYLTHIOURACIL 50 MG TAB,2500015860,CDM,637,RC,480924201,NDC,999,EAPG,,,,outpatient,facility,50,UN,2.97,2.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PSEUDOEPHEDRINE 30 MG TAB,2500015902,CDM,637,RC,904505359,NDC,,,,,,inpatient,facility,30,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
PSEUDOEPHEDRINE 30 MG TAB,2500015902,CDM,637,RC,904505359,NDC,,,,,,outpatient,facility,30,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
PSEUDOEPHEDRINE 30 MG TAB,2500015902,CDM,637,RC,904505359,NDC,999,EAPG,,,,outpatient,facility,30,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PSYLLIUM 5.85 GM PACK,2500015910,CDM,637,RC,5192715520,NDC,,,,,,inpatient,facility,1,UN,1.85,1.85,0.15,1.85,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,
PSYLLIUM 5.85 GM PACK,2500015910,CDM,637,RC,5192715520,NDC,,,,,,outpatient,facility,1,UN,1.85,1.85,0.15,548.68,,1.31,,,percent of total billed charges,,,0.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.85,,,percent of total billed charges,,,1.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.68,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.85,,,fee schedule,,,1.85,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,548.68,,,per diem,,,1.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.85,,,percent of total billed charges,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.74,,,percent of total billed charges,,,,,,,,,0.68,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.72,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.09,,,percent of total billed charges,,
PSYLLIUM 5.85 GM PACK,2500015910,CDM,637,RC,5192715520,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.85,1.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PYRAZINAMIDE 500 MG TAB,2500015940,CDM,637,RC,6174801201,NDC,,,,,,inpatient,facility,500,UN,20.29,20.29,1.62,20.29,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,,,,,,,20.29,,,percent of total billed charges,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.17,,,percent of total billed charges,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,17.25,,,percent of total billed charges,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,10.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,20.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,
PYRAZINAMIDE 500 MG TAB,2500015940,CDM,637,RC,6174801201,NDC,,,,,,outpatient,facility,500,UN,20.29,20.29,1.62,548.68,,14.39,,,percent of total billed charges,,,4.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,20.29,,,percent of total billed charges,,,12.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,14.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,14.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.43,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,20.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,20.29,,,fee schedule,,,20.29,,,percent of total billed charges,,,,,,,,,20.29,,,percent of total billed charges,,,12.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.46,,,percent of total billed charges,,,,,,,,,,,,,,,10.96,,,percent of total billed charges,,,10.55,,,percent of total billed charges,,,11.16,,,percent of total billed charges,,,,,,,,,11.97,,,percent of total billed charges,,,548.68,,,per diem,,,20.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,20.29,,,percent of total billed charges,,,17.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.78,,,percent of total billed charges,,,20.29,,,percent of total billed charges,,,20.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,16.42,,,percent of total billed charges,,,,,,,,,,,,,,,8.12,,,percent of total billed charges,,,,,,,,,7.51,,,percent of total billed charges,,,7.51,,,percent of total billed charges,,,,,,,,,20.29,,,percent of total billed charges,,,20.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.62,,,percent of total billed charges,,,20.29,,,percent of total billed charges,,,,,,,,,,,,,,,20.29,,,percent of total billed charges,,,20.29,,,percent of total billed charges,,,,,,,,,18.87,,,percent of total billed charges,,,,,,,,,,,,,,,18.87,,,percent of total billed charges,,,18.87,,,percent of total billed charges,,,18.87,,,percent of total billed charges,,,15.22,,,percent of total billed charges,,,20.29,,,percent of total billed charges,,,20.29,,,percent of total billed charges,,,20.29,,,percent of total billed charges,,,,,,,,,14.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.95,,,percent of total billed charges,,
PYRAZINAMIDE 500 MG TAB,2500015940,CDM,637,RC,6174801201,NDC,999,EAPG,,,,outpatient,facility,500,UN,20.29,20.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PYRIDOSTIGMINE 60 MG TAB,2500015961,CDM,637,RC,904662261,NDC,,,,,,inpatient,facility,60,UN,4.42,4.42,0.35,4.42,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.6,,,percent of total billed charges,,
PYRIDOSTIGMINE 60 MG TAB,2500015961,CDM,637,RC,904662261,NDC,,,,,,outpatient,facility,60,UN,4.42,4.42,0.35,548.68,,3.13,,,percent of total billed charges,,,1.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.42,,,percent of total billed charges,,,2.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.62,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.42,,,fee schedule,,,4.42,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,2.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.15,,,percent of total billed charges,,,,,,,,,,,,,,,2.39,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,,,,,,,2.61,,,percent of total billed charges,,,548.68,,,per diem,,,4.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.42,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,1.64,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,4.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.35,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,4.11,,,percent of total billed charges,,,,,,,,,,,,,,,4.11,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.6,,,percent of total billed charges,,
PYRIDOSTIGMINE 60 MG TAB,2500015961,CDM,637,RC,904662261,NDC,999,EAPG,,,,outpatient,facility,60,UN,4.42,4.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PYRIDOXINE 25 MG TAB,2500015971,CDM,637,RC,536440601,NDC,,,,,,inpatient,facility,25,UN,0.07,0.07,0.01,0.07,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,,,,,,,0.07,,,percent of total billed charges,,,0.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.06,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,
PYRIDOXINE 25 MG TAB,2500015971,CDM,637,RC,536440601,NDC,,,,,,outpatient,facility,25,UN,0.07,0.07,0.01,548.68,,0.05,,,percent of total billed charges,,,0.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.03,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.07,,,fee schedule,,,0.07,,,percent of total billed charges,,,,,,,,,0.07,,,percent of total billed charges,,,0.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.04,,,percent of total billed charges,,,0.04,,,percent of total billed charges,,,,,,,,,0.04,,,percent of total billed charges,,,548.68,,,per diem,,,0.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.07,,,percent of total billed charges,,,0.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.06,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,0.07,,,percent of total billed charges,,,0.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,,,,,,,0.07,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,0.05,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,,,,,,,0.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.04,,,percent of total billed charges,,
PYRIDOXINE 25 MG TAB,2500015971,CDM,637,RC,536440601,NDC,999,EAPG,,,,outpatient,facility,25,UN,0.07,0.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PYRIDOXINE 50 MG TAB,2500015972,CDM,637,RC,7733394010,NDC,,,,,,inpatient,facility,50,UN,1.01,1.01,0.08,1.01,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,1.01,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,
PYRIDOXINE 50 MG TAB,2500015972,CDM,637,RC,7733394010,NDC,,,,,,outpatient,facility,50,UN,1.01,1.01,0.08,548.68,,0.72,,,percent of total billed charges,,,0.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.01,,,percent of total billed charges,,,0.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.37,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.01,,,fee schedule,,,1.01,,,percent of total billed charges,,,,,,,,,1.01,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.6,,,percent of total billed charges,,,548.68,,,per diem,,,1.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.01,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,0.37,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,1.01,,,percent of total billed charges,,,1.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,0.76,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.6,,,percent of total billed charges,,
PYRIDOXINE 50 MG TAB,2500015972,CDM,637,RC,7733394010,NDC,999,EAPG,,,,outpatient,facility,50,UN,1.01,1.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
QUETIAPINE 100 MG TAB,2500015990,CDM,637,RC,904664061,NDC,,,,,,inpatient,facility,100,UN,1.55,1.55,0.12,1.55,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,
QUETIAPINE 100 MG TAB,2500015990,CDM,637,RC,904664061,NDC,,,,,,outpatient,facility,100,UN,1.55,1.55,0.12,548.68,,1.1,,,percent of total billed charges,,,0.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.55,,,percent of total billed charges,,,0.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.55,,,fee schedule,,,1.55,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,0.91,,,percent of total billed charges,,,548.68,,,per diem,,,1.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.55,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,0.57,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,1.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.12,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,1.44,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.91,,,percent of total billed charges,,
QUETIAPINE 100 MG TAB,2500015990,CDM,637,RC,904664061,NDC,999,EAPG,,,,outpatient,facility,100,UN,1.55,1.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
QUETIAPINE 25 MG TAB,2500015991,CDM,637,RC,904663861,NDC,,,,,,inpatient,facility,25,UN,0.95,0.95,0.08,0.95,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,
QUETIAPINE 25 MG TAB,2500015991,CDM,637,RC,904663861,NDC,,,,,,outpatient,facility,25,UN,0.95,0.95,0.08,548.68,,0.67,,,percent of total billed charges,,,0.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.95,,,percent of total billed charges,,,0.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.35,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.95,,,fee schedule,,,0.95,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,548.68,,,per diem,,,0.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.95,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,0.35,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,0.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.56,,,percent of total billed charges,,
QUETIAPINE 25 MG TAB,2500015991,CDM,637,RC,904663861,NDC,999,EAPG,,,,outpatient,facility,25,UN,0.95,0.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
QUETIAPINE 200 MG TAB,2500015992,CDM,637,RC,904664161,NDC,,,,,,inpatient,facility,200,UN,3.14,3.14,0.25,3.14,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,,,,,,,3.14,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,
QUETIAPINE 200 MG TAB,2500015992,CDM,637,RC,904664161,NDC,,,,,,outpatient,facility,200,UN,3.14,3.14,0.25,548.68,,2.23,,,percent of total billed charges,,,0.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.14,,,percent of total billed charges,,,1.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.15,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.14,,,fee schedule,,,3.14,,,percent of total billed charges,,,,,,,,,3.14,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,548.68,,,per diem,,,3.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.14,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.26,,,percent of total billed charges,,,,,,,,,1.16,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,3.14,,,percent of total billed charges,,,3.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.25,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,,,,,,,2.92,,,percent of total billed charges,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,,2.92,,,percent of total billed charges,,,2.92,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,3.14,,,percent of total billed charges,,,,,,,,,2.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.85,,,percent of total billed charges,,
QUETIAPINE 200 MG TAB,2500015992,CDM,637,RC,904664161,NDC,999,EAPG,,,,outpatient,facility,200,UN,3.14,3.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
QUETIAPINE 400 MG TAB,2500015996,CDM,637,RC,904664361,NDC,,,,,,inpatient,facility,400,UN,4.62,4.62,0.37,4.62,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,4.62,,,percent of total billed charges,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,2.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,
QUETIAPINE 400 MG TAB,2500015996,CDM,637,RC,904664361,NDC,,,,,,outpatient,facility,400,UN,4.62,4.62,0.37,548.68,,3.28,,,percent of total billed charges,,,1.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.62,,,percent of total billed charges,,,2.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.69,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.62,,,fee schedule,,,4.62,,,percent of total billed charges,,,,,,,,,4.62,,,percent of total billed charges,,,2.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.29,,,percent of total billed charges,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,2.73,,,percent of total billed charges,,,548.68,,,per diem,,,4.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.62,,,percent of total billed charges,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,3.74,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,1.71,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,4.62,,,percent of total billed charges,,,4.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.37,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,4.3,,,percent of total billed charges,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,4.62,,,percent of total billed charges,,,,,,,,,3.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.72,,,percent of total billed charges,,
QUETIAPINE 400 MG TAB,2500015996,CDM,637,RC,904664361,NDC,999,EAPG,,,,outpatient,facility,400,UN,4.62,4.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
QUETIAPINE 50 MG TABXR,2500015999,CDM,637,RC,6818061207,NDC,,,,,,inpatient,facility,50,UN,29.27,29.27,2.34,29.27,,,,,,,,,,,,,,29.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.27,,,percent of total billed charges,,,,,,,,,29.27,,,percent of total billed charges,,,14.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,29.27,,,percent of total billed charges,,,24.88,,,percent of total billed charges,,,,,,,,,,,,,,,29.27,,,percent of total billed charges,,,15.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,29.27,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,29.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.25,,,percent of total billed charges,,
QUETIAPINE 50 MG TABXR,2500015999,CDM,637,RC,6818061207,NDC,,,,,,outpatient,facility,50,UN,29.27,29.27,2.34,548.68,,20.76,,,percent of total billed charges,,,7.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,29.27,,,percent of total billed charges,,,18.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,20.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,20.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,29.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,29.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,29.27,,,fee schedule,,,29.27,,,percent of total billed charges,,,,,,,,,29.27,,,percent of total billed charges,,,17.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.85,,,percent of total billed charges,,,,,,,,,,,,,,,15.81,,,percent of total billed charges,,,15.22,,,percent of total billed charges,,,16.1,,,percent of total billed charges,,,,,,,,,17.27,,,percent of total billed charges,,,548.68,,,per diem,,,29.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,29.27,,,percent of total billed charges,,,24.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.55,,,percent of total billed charges,,,29.27,,,percent of total billed charges,,,29.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.75,,,percent of total billed charges,,,23.69,,,percent of total billed charges,,,,,,,,,,,,,,,11.71,,,percent of total billed charges,,,,,,,,,10.83,,,percent of total billed charges,,,10.83,,,percent of total billed charges,,,,,,,,,29.27,,,percent of total billed charges,,,29.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.34,,,percent of total billed charges,,,29.27,,,percent of total billed charges,,,,,,,,,,,,,,,29.27,,,percent of total billed charges,,,29.27,,,percent of total billed charges,,,,,,,,,27.23,,,percent of total billed charges,,,,,,,,,,,,,,,27.23,,,percent of total billed charges,,,27.23,,,percent of total billed charges,,,27.23,,,percent of total billed charges,,,21.95,,,percent of total billed charges,,,29.27,,,percent of total billed charges,,,29.27,,,percent of total billed charges,,,29.27,,,percent of total billed charges,,,,,,,,,20.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.25,,,percent of total billed charges,,
QUETIAPINE 50 MG TABXR,2500015999,CDM,637,RC,6818061207,NDC,999,EAPG,,,,outpatient,facility,50,UN,29.27,29.27,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RACEPINEPHRINE 2.25  NEB 0.5ML,2500016063,CDM,637,RC,487278401,NDC,,,,,,inpatient,facility,0.5,UN,3.75,3.75,0.3,3.75,,,,,,,,,,,,,,3.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.75,,,percent of total billed charges,,,,,,,,,3.75,,,percent of total billed charges,,,1.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.25,,,percent of total billed charges,,,,,,,,,,,,,,,3.75,,,percent of total billed charges,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,3.75,,,percent of total billed charges,,,1.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.75,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,
RACEPINEPHRINE 2.25  NEB 0.5ML,2500016063,CDM,637,RC,487278401,NDC,,,,,,outpatient,facility,0.5,UN,3.75,3.75,0.3,548.68,,2.66,,,percent of total billed charges,,,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.75,,,percent of total billed charges,,,2.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.37,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.75,,,fee schedule,,,3.75,,,percent of total billed charges,,,,,,,,,3.75,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,548.68,,,per diem,,,3.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.75,,,percent of total billed charges,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,1.39,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,,,,,,,3.75,,,percent of total billed charges,,,3.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.3,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,,,,,,,,,,,,,3.75,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,,,,,,,3.49,,,percent of total billed charges,,,,,,,,,,,,,,,3.49,,,percent of total billed charges,,,3.49,,,percent of total billed charges,,,3.49,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,,,,,,,2.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.21,,,percent of total billed charges,,
RACEPINEPHRINE 2.25  NEB 0.5ML,2500016063,CDM,637,RC,487278401,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,3.75,3.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RALOXIFENE HCL 60 MG TAB,2500016070,CDM,637,RC,5026869415,NDC,,,,,,inpatient,facility,60,UN,23.53,23.53,1.88,23.53,,,,,,,,,,,,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.53,,,percent of total billed charges,,,,,,,,,23.53,,,percent of total billed charges,,,12.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,23.53,,,percent of total billed charges,,,20,,,percent of total billed charges,,,,,,,,,,,,,,,23.53,,,percent of total billed charges,,,12.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.86,,,percent of total billed charges,,
RALOXIFENE HCL 60 MG TAB,2500016070,CDM,637,RC,5026869415,NDC,,,,,,outpatient,facility,60,UN,23.53,23.53,1.88,548.68,,16.69,,,percent of total billed charges,,,5.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,23.53,,,percent of total billed charges,,,14.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,16.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,16.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,23.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,23.53,,,fee schedule,,,23.53,,,percent of total billed charges,,,,,,,,,23.53,,,percent of total billed charges,,,14.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.77,,,percent of total billed charges,,,,,,,,,,,,,,,12.71,,,percent of total billed charges,,,12.24,,,percent of total billed charges,,,12.94,,,percent of total billed charges,,,,,,,,,13.88,,,percent of total billed charges,,,548.68,,,per diem,,,23.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,23.53,,,percent of total billed charges,,,20,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.5,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.87,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,9.41,,,percent of total billed charges,,,,,,,,,8.71,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,,,,,,,23.53,,,percent of total billed charges,,,23.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.88,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,,,,,,,,,,,,,23.53,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,,,,,,,21.89,,,percent of total billed charges,,,,,,,,,,,,,,,21.89,,,percent of total billed charges,,,21.89,,,percent of total billed charges,,,21.89,,,percent of total billed charges,,,17.65,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,23.53,,,percent of total billed charges,,,,,,,,,16.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.86,,,percent of total billed charges,,
RALOXIFENE HCL 60 MG TAB,2500016070,CDM,637,RC,5026869415,NDC,999,EAPG,,,,outpatient,facility,60,UN,23.53,23.53,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RAMELTEON 8 MG TAB,2500016075,CDM,637,RC,832125011,NDC,,,,,,inpatient,facility,8,UN,46.17,46.17,3.69,46.17,,,,,,,,,,,,,,46.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.17,,,percent of total billed charges,,,,,,,,,46.17,,,percent of total billed charges,,,23.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.7,,,percent of total billed charges,,,,,,,,,,,,,,,46.17,,,percent of total billed charges,,,39.24,,,percent of total billed charges,,,,,,,,,,,,,,,46.17,,,percent of total billed charges,,,24.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,46.17,,,percent of total billed charges,,,,,,,,,,,,,,,3.69,,,percent of total billed charges,,,46.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.2,,,percent of total billed charges,,
RAMELTEON 8 MG TAB,2500016075,CDM,637,RC,832125011,NDC,,,,,,outpatient,facility,8,UN,46.17,46.17,3.69,548.68,,32.74,,,percent of total billed charges,,,11.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,46.17,,,percent of total billed charges,,,28.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,32.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,32.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,46.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,16.9,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,46.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,46.17,,,fee schedule,,,46.17,,,percent of total billed charges,,,,,,,,,46.17,,,percent of total billed charges,,,28.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.9,,,percent of total billed charges,,,,,,,,,,,,,,,24.93,,,percent of total billed charges,,,24.01,,,percent of total billed charges,,,25.39,,,percent of total billed charges,,,,,,,,,27.24,,,percent of total billed charges,,,548.68,,,per diem,,,46.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,46.17,,,percent of total billed charges,,,39.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.52,,,percent of total billed charges,,,46.17,,,percent of total billed charges,,,46.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.15,,,percent of total billed charges,,,37.36,,,percent of total billed charges,,,,,,,,,,,,,,,18.47,,,percent of total billed charges,,,,,,,,,17.08,,,percent of total billed charges,,,17.08,,,percent of total billed charges,,,,,,,,,46.17,,,percent of total billed charges,,,46.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.69,,,percent of total billed charges,,,46.17,,,percent of total billed charges,,,,,,,,,,,,,,,46.17,,,percent of total billed charges,,,46.17,,,percent of total billed charges,,,,,,,,,42.95,,,percent of total billed charges,,,,,,,,,,,,,,,42.95,,,percent of total billed charges,,,42.95,,,percent of total billed charges,,,42.95,,,percent of total billed charges,,,34.63,,,percent of total billed charges,,,46.17,,,percent of total billed charges,,,46.17,,,percent of total billed charges,,,46.17,,,percent of total billed charges,,,,,,,,,32.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,27.2,,,percent of total billed charges,,
RAMELTEON 8 MG TAB,2500016075,CDM,637,RC,832125011,NDC,999,EAPG,,,,outpatient,facility,8,UN,46.17,46.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RAMUCIRUMAB 100 MG INJ,2500016085,CDM,636,RC,J9308,HCPCS,2766901,NDC,,,,inpatient,facility,10,ML,4713.15,4713.15,377.05,4713.15,,,,,,,,,,,,,,4713.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4713.15,,,percent of total billed charges,,,,,,,,,4713.15,,,percent of total billed charges,,,2406.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4014.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2827.89,,,percent of total billed charges,,,,,,,,,,,,,,,4713.15,,,percent of total billed charges,,,4006.18,,,percent of total billed charges,,,,,,,,,,,,,,,4713.15,,,percent of total billed charges,,,2503.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1885.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4713.15,,,percent of total billed charges,,,,,,,,,,,,,,,377.05,,,percent of total billed charges,,,4713.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4713.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2776.99,,,percent of total billed charges,,
RAMUCIRUMAB 100 MG INJ,2500016085,CDM,636,RC,J9308,HCPCS,2766901,NDC,,,,outpatient,facility,10,ML,4713.15,4713.15,44.79,4713.15,,69.65,,,fee schedule,,,,,,,,,4713.15,,,percent of total billed charges,,,92.5,,,fee schedule,,,87.51,,,fee schedule,,,,,,,,,87.51,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4713.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4713.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4713.15,,,fee schedule,,,4713.15,,,percent of total billed charges,,,,,,,,,4713.15,,,percent of total billed charges,,,2888.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3358.12,,,percent of total billed charges,,,,,,,,,,,,,,,70.24,,,fee schedule,,,70.24,,,fee schedule,,,70.24,,,fee schedule,,,,,,,,,2780.76,,,percent of total billed charges,,,548.68,,,per diem,,,4713.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4713.15,,,percent of total billed charges,,,4006.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2503.15,,,percent of total billed charges,,,4713.15,,,percent of total billed charges,,,4713.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3179.49,,,percent of total billed charges,,,3813.88,,,percent of total billed charges,,,,,,,,,,,,,,,1885.26,,,percent of total billed charges,,,,,,,,,161.23,,,fee schedule,,,116.02,,,fee schedule,,,,,,,,,4713.15,,,percent of total billed charges,,,,,,,,,,,,,,,377.05,,,percent of total billed charges,,,4713.15,,,percent of total billed charges,,,,,,,,,,,,,,,4713.15,,,percent of total billed charges,,,4713.15,,,percent of total billed charges,,,,,,,,,68.9,,,fee schedule,,,,,,,,,,,,,,,59.72,,,fee schedule,,,79.62,,,fee schedule,,,44.79,,,fee schedule,,,73.95,,,fee schedule,,,4713.15,,,percent of total billed charges,,,4713.15,,,percent of total billed charges,,,4713.15,,,percent of total billed charges,,,,,,,,,3304.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2356.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2776.99,,,percent of total billed charges,,
RAMUCIRUMAB 100 MG INJ,2500016085,CDM,636,RC,J9308,HCPCS,2766901,NDC,1488,APC,,outpatient,facility,10,ML,4713.15,4713.15,69.99,1725.01,,,,,,,,75.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,72.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.64,,,fee schedule,,,,,,,,,1725.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,72.91,,,fee schedule,,,,,,,,,,,,,,,76.56,,,fee schedule,,,76.56,,,fee schedule,,,,,,,,,72.91,,,fee schedule,,,72.91,,,fee schedule,,,76.56,,,fee schedule,,,,,,,,,,,,,,,109.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,72.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.99,,,fee schedule,,,78.01,,,fee schedule,,,76.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.91,,,fee schedule,,,72.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,75.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,72.91,,,fee schedule,,,,,,,,,91.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,91.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,72.91,,,fee schedule,,,72.91,,,fee schedule,,,,,,,,,,,,,,,72.91,,,fee schedule,,,,,,,,,72.91,,,fee schedule,,,75.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.91,,,fee schedule,,,,,,,,,,,,,,,75.83,,,fee schedule,,,72.91,,,fee schedule,,,,,,,,,72.91,,,fee schedule,,,,,,,,,72.91,,,fee schedule,,,76.56,,,fee schedule,,,,,,,,
RAMUCIRUMAB 100 MG INJ,2500016085,CDM,636,RC,J9308,HCPCS,2766901,NDC,463,EAPG,,outpatient,facility,10,ML,4713.15,4713.15,7053.67,10651.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10651.04,,,fee schedule,,,7053.67,,,fee schedule,,,9468.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RAMUCIRUMAB 500 MG INJ,2500016086,CDM,636,RC,J9308,HCPCS,2767801,NDC,,,,inpatient,facility,50,ML,24037.03,24037.03,1922.96,24037.03,,,,,,,,,,,,,,24037.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24037.03,,,percent of total billed charges,,,,,,,,,24037.03,,,percent of total billed charges,,,12273.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20472.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14422.22,,,percent of total billed charges,,,,,,,,,,,,,,,24037.03,,,percent of total billed charges,,,20431.48,,,percent of total billed charges,,,,,,,,,,,,,,,24037.03,,,percent of total billed charges,,,12766.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9614.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,24037.03,,,percent of total billed charges,,,,,,,,,,,,,,,1922.96,,,percent of total billed charges,,,24037.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24037.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14162.62,,,percent of total billed charges,,
RAMUCIRUMAB 500 MG INJ,2500016086,CDM,636,RC,J9308,HCPCS,2767801,NDC,,,,outpatient,facility,50,ML,24037.03,24037.03,44.79,24037.03,,69.65,,,fee schedule,,,,,,,,,24037.03,,,percent of total billed charges,,,92.5,,,fee schedule,,,87.51,,,fee schedule,,,,,,,,,87.51,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24037.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,24037.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,24037.03,,,fee schedule,,,24037.03,,,percent of total billed charges,,,,,,,,,24037.03,,,percent of total billed charges,,,14732.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17126.38,,,percent of total billed charges,,,,,,,,,,,,,,,70.24,,,fee schedule,,,70.24,,,fee schedule,,,70.24,,,fee schedule,,,,,,,,,14181.85,,,percent of total billed charges,,,548.68,,,per diem,,,24037.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,24037.03,,,percent of total billed charges,,,20431.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12766.07,,,percent of total billed charges,,,24037.03,,,percent of total billed charges,,,24037.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16215.38,,,percent of total billed charges,,,19450.76,,,percent of total billed charges,,,,,,,,,,,,,,,9614.81,,,percent of total billed charges,,,,,,,,,161.23,,,fee schedule,,,116.02,,,fee schedule,,,,,,,,,24037.03,,,percent of total billed charges,,,,,,,,,,,,,,,1922.96,,,percent of total billed charges,,,24037.03,,,percent of total billed charges,,,,,,,,,,,,,,,24037.03,,,percent of total billed charges,,,24037.03,,,percent of total billed charges,,,,,,,,,68.9,,,fee schedule,,,,,,,,,,,,,,,59.72,,,fee schedule,,,79.62,,,fee schedule,,,44.79,,,fee schedule,,,73.95,,,fee schedule,,,24037.03,,,percent of total billed charges,,,24037.03,,,percent of total billed charges,,,24037.03,,,percent of total billed charges,,,,,,,,,16852.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12018.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14162.62,,,percent of total billed charges,,
RAMUCIRUMAB 500 MG INJ,2500016086,CDM,636,RC,J9308,HCPCS,2767801,NDC,1488,APC,,outpatient,facility,50,ML,24037.03,24037.03,69.99,8797.55,,,,,,,,75.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,72.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.64,,,fee schedule,,,,,,,,,8797.55,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,72.91,,,fee schedule,,,,,,,,,,,,,,,76.56,,,fee schedule,,,76.56,,,fee schedule,,,,,,,,,72.91,,,fee schedule,,,72.91,,,fee schedule,,,76.56,,,fee schedule,,,,,,,,,,,,,,,109.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,72.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.99,,,fee schedule,,,78.01,,,fee schedule,,,76.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.91,,,fee schedule,,,72.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,75.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,72.91,,,fee schedule,,,,,,,,,91.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,91.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,72.91,,,fee schedule,,,72.91,,,fee schedule,,,,,,,,,,,,,,,72.91,,,fee schedule,,,,,,,,,72.91,,,fee schedule,,,75.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.91,,,fee schedule,,,,,,,,,,,,,,,75.83,,,fee schedule,,,72.91,,,fee schedule,,,,,,,,,72.91,,,fee schedule,,,,,,,,,72.91,,,fee schedule,,,76.56,,,fee schedule,,,,,,,,
RAMUCIRUMAB 500 MG INJ,2500016086,CDM,636,RC,J9308,HCPCS,2767801,NDC,463,EAPG,,outpatient,facility,50,ML,24037.03,24037.03,7053.67,10651.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10651.04,,,fee schedule,,,7053.67,,,fee schedule,,,9468.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REMIFENTANIL 1 MG INJ,2500016110,CDM,250,RC,J3490,HCPCS,6332372303,NDC,,,,inpatient,facility,1,UN,241.92,241.92,19.35,241.92,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,241.92,,,percent of total billed charges,,,123.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.15,,,percent of total billed charges,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,205.63,,,percent of total billed charges,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,128.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,19.35,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.54,,,percent of total billed charges,,
REMIFENTANIL 1 MG INJ,2500016110,CDM,250,RC,J3490,HCPCS,6332372303,NDC,,,,outpatient,facility,1,UN,241.92,241.92,1.2,548.68,,171.55,,,percent of total billed charges,,,59.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,241.92,,,percent of total billed charges,,,151.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,170.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,170.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,88.54,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,241.92,,,fee schedule,,,241.92,,,percent of total billed charges,,,,,,,,,241.92,,,percent of total billed charges,,,148.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.37,,,percent of total billed charges,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,142.73,,,percent of total billed charges,,,548.68,,,per diem,,,241.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,241.92,,,percent of total billed charges,,,205.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,128.48,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.2,,,percent of total billed charges,,,195.76,,,percent of total billed charges,,,,,,,,,,,,,,,96.77,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,241.92,,,percent of total billed charges,,,241.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,241.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.35,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,181.44,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,241.92,,,percent of total billed charges,,,,,,,,,169.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,142.54,,,percent of total billed charges,,
REMIFENTANIL 1 MG INJ,2500016110,CDM,250,RC,J3490,HCPCS,6332372303,NDC,435,EAPG,,outpatient,facility,1,UN,241.92,241.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REMIFENTANIL 2 MG INJ,2500016112,CDM,250,RC,6332372405,NDC,,,,,,inpatient,facility,2,UN,424.45,424.45,33.96,424.45,,,,,,,,,,,,,,424.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,424.45,,,percent of total billed charges,,,,,,,,,424.45,,,percent of total billed charges,,,216.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,361.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.67,,,percent of total billed charges,,,,,,,,,,,,,,,424.45,,,percent of total billed charges,,,360.78,,,percent of total billed charges,,,,,,,,,,,,,,,424.45,,,percent of total billed charges,,,225.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,424.45,,,percent of total billed charges,,,,,,,,,,,,,,,33.96,,,percent of total billed charges,,,424.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,424.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.09,,,percent of total billed charges,,
REMIFENTANIL 2 MG INJ,2500016112,CDM,250,RC,6332372405,NDC,,,,,,outpatient,facility,2,UN,424.45,424.45,33.96,548.68,,300.98,,,percent of total billed charges,,,103.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,424.45,,,percent of total billed charges,,,266,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,298.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,298.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,424.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,155.35,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,424.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,424.45,,,fee schedule,,,424.45,,,percent of total billed charges,,,,,,,,,424.45,,,percent of total billed charges,,,260.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,250.43,,,percent of total billed charges,,,548.68,,,per diem,,,424.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,424.45,,,percent of total billed charges,,,360.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,225.43,,,percent of total billed charges,,,424.45,,,percent of total billed charges,,,424.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,286.33,,,percent of total billed charges,,,343.46,,,percent of total billed charges,,,,,,,,,,,,,,,169.78,,,percent of total billed charges,,,,,,,,,169.78,,,percent of total billed charges,,,169.78,,,percent of total billed charges,,,,,,,,,424.45,,,percent of total billed charges,,,424.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,424.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33.96,,,percent of total billed charges,,,424.45,,,percent of total billed charges,,,,,,,,,,,,,,,424.45,,,percent of total billed charges,,,424.45,,,percent of total billed charges,,,,,,,,,169.78,,,percent of total billed charges,,,,,,,,,,,,,,,169.78,,,percent of total billed charges,,,169.78,,,percent of total billed charges,,,169.78,,,percent of total billed charges,,,318.34,,,percent of total billed charges,,,424.45,,,percent of total billed charges,,,424.45,,,percent of total billed charges,,,424.45,,,percent of total billed charges,,,,,,,,,297.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,212.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,250.09,,,percent of total billed charges,,
REMIFENTANIL 2 MG INJ,2500016112,CDM,250,RC,6332372405,NDC,999,EAPG,,,,outpatient,facility,2,UN,424.45,424.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REPAGLINIDE 0.5 MG TAB,2500016130,CDM,637,RC,5723715701,NDC,,,,,,inpatient,facility,0.5,UN,12.08,12.08,0.97,12.08,,,,,,,,,,,,,,12.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.08,,,percent of total billed charges,,,,,,,,,12.08,,,percent of total billed charges,,,6.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,12.08,,,percent of total billed charges,,,10.27,,,percent of total billed charges,,,,,,,,,,,,,,,12.08,,,percent of total billed charges,,,6.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12.08,,,percent of total billed charges,,,,,,,,,,,,,,,0.97,,,percent of total billed charges,,,12.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.12,,,percent of total billed charges,,
REPAGLINIDE 0.5 MG TAB,2500016130,CDM,637,RC,5723715701,NDC,,,,,,outpatient,facility,0.5,UN,12.08,12.08,0.97,548.68,,8.57,,,percent of total billed charges,,,2.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,12.08,,,percent of total billed charges,,,7.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.42,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,12.08,,,fee schedule,,,12.08,,,percent of total billed charges,,,,,,,,,12.08,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.61,,,percent of total billed charges,,,,,,,,,,,,,,,6.52,,,percent of total billed charges,,,6.28,,,percent of total billed charges,,,6.64,,,percent of total billed charges,,,,,,,,,7.13,,,percent of total billed charges,,,548.68,,,per diem,,,12.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12.08,,,percent of total billed charges,,,10.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.42,,,percent of total billed charges,,,12.08,,,percent of total billed charges,,,12.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,percent of total billed charges,,,9.78,,,percent of total billed charges,,,,,,,,,,,,,,,4.83,,,percent of total billed charges,,,,,,,,,4.47,,,percent of total billed charges,,,4.47,,,percent of total billed charges,,,,,,,,,12.08,,,percent of total billed charges,,,12.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.97,,,percent of total billed charges,,,12.08,,,percent of total billed charges,,,,,,,,,,,,,,,12.08,,,percent of total billed charges,,,12.08,,,percent of total billed charges,,,,,,,,,11.24,,,percent of total billed charges,,,,,,,,,,,,,,,11.24,,,percent of total billed charges,,,11.24,,,percent of total billed charges,,,11.24,,,percent of total billed charges,,,9.06,,,percent of total billed charges,,,12.08,,,percent of total billed charges,,,12.08,,,percent of total billed charges,,,12.08,,,percent of total billed charges,,,,,,,,,8.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.12,,,percent of total billed charges,,
REPAGLINIDE 0.5 MG TAB,2500016130,CDM,637,RC,5723715701,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,12.08,12.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
REPAGLINIDE 1 MG TAB,2500016131,CDM,637,RC,5723715801,NDC,,,,,,inpatient,facility,1,UN,12.07,12.07,0.97,12.07,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,,,,,,,,12.07,,,percent of total billed charges,,,6.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.24,,,percent of total billed charges,,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,,6.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,0.97,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.11,,,percent of total billed charges,,
REPAGLINIDE 1 MG TAB,2500016131,CDM,637,RC,5723715801,NDC,,,,,,outpatient,facility,1,UN,12.07,12.07,0.97,548.68,,8.56,,,percent of total billed charges,,,2.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,12.07,,,percent of total billed charges,,,7.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.42,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,12.07,,,fee schedule,,,12.07,,,percent of total billed charges,,,,,,,,,12.07,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.6,,,percent of total billed charges,,,,,,,,,,,,,,,6.52,,,percent of total billed charges,,,6.28,,,percent of total billed charges,,,6.64,,,percent of total billed charges,,,,,,,,,7.12,,,percent of total billed charges,,,548.68,,,per diem,,,12.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12.07,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.41,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.14,,,percent of total billed charges,,,9.77,,,percent of total billed charges,,,,,,,,,,,,,,,4.83,,,percent of total billed charges,,,,,,,,,4.47,,,percent of total billed charges,,,4.47,,,percent of total billed charges,,,,,,,,,12.07,,,percent of total billed charges,,,12.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.97,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,,,,,,,,,,,,,12.07,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,,,,,,,11.23,,,percent of total billed charges,,,,,,,,,,,,,,,11.23,,,percent of total billed charges,,,11.23,,,percent of total billed charges,,,11.23,,,percent of total billed charges,,,9.05,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,12.07,,,percent of total billed charges,,,,,,,,,8.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.11,,,percent of total billed charges,,
REPAGLINIDE 1 MG TAB,2500016131,CDM,637,RC,5723715801,NDC,999,EAPG,,,,outpatient,facility,1,UN,12.07,12.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIFAMPIN 300 MG CAP,2500016172,CDM,637,RC,527131501,NDC,,,,,,inpatient,facility,300,UN,15.15,15.15,1.21,15.15,,,,,,,,,,,,,,15.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.15,,,percent of total billed charges,,,,,,,,,15.15,,,percent of total billed charges,,,7.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.09,,,percent of total billed charges,,,,,,,,,,,,,,,15.15,,,percent of total billed charges,,,12.88,,,percent of total billed charges,,,,,,,,,,,,,,,15.15,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,15.15,,,percent of total billed charges,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,15.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.93,,,percent of total billed charges,,
RIFAMPIN 300 MG CAP,2500016172,CDM,637,RC,527131501,NDC,,,,,,outpatient,facility,300,UN,15.15,15.15,1.21,548.68,,10.74,,,percent of total billed charges,,,3.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,15.15,,,percent of total billed charges,,,9.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,15.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.54,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,15.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,15.15,,,fee schedule,,,15.15,,,percent of total billed charges,,,,,,,,,15.15,,,percent of total billed charges,,,9.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.79,,,percent of total billed charges,,,,,,,,,,,,,,,8.18,,,percent of total billed charges,,,7.88,,,percent of total billed charges,,,8.33,,,percent of total billed charges,,,,,,,,,8.94,,,percent of total billed charges,,,548.68,,,per diem,,,15.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,15.15,,,percent of total billed charges,,,12.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,15.15,,,percent of total billed charges,,,15.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.22,,,percent of total billed charges,,,12.26,,,percent of total billed charges,,,,,,,,,,,,,,,6.06,,,percent of total billed charges,,,,,,,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,15.15,,,percent of total billed charges,,,15.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.21,,,percent of total billed charges,,,15.15,,,percent of total billed charges,,,,,,,,,,,,,,,15.15,,,percent of total billed charges,,,15.15,,,percent of total billed charges,,,,,,,,,14.09,,,percent of total billed charges,,,,,,,,,,,,,,,14.09,,,percent of total billed charges,,,14.09,,,percent of total billed charges,,,14.09,,,percent of total billed charges,,,11.36,,,percent of total billed charges,,,15.15,,,percent of total billed charges,,,15.15,,,percent of total billed charges,,,15.15,,,percent of total billed charges,,,,,,,,,10.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.93,,,percent of total billed charges,,
RIFAMPIN 300 MG CAP,2500016172,CDM,637,RC,527131501,NDC,999,EAPG,,,,outpatient,facility,300,UN,15.15,15.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIFAXIMIN 200 MG TAB,2500016179,CDM,637,RC,6564930103,NDC,,,,,,inpatient,facility,200,UN,33.79,33.79,2.7,33.79,,,,,,,,,,,,,,33.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.79,,,percent of total billed charges,,,,,,,,,33.79,,,percent of total billed charges,,,17.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.27,,,percent of total billed charges,,,,,,,,,,,,,,,33.79,,,percent of total billed charges,,,28.72,,,percent of total billed charges,,,,,,,,,,,,,,,33.79,,,percent of total billed charges,,,17.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,33.79,,,percent of total billed charges,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,33.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.91,,,percent of total billed charges,,
RIFAXIMIN 200 MG TAB,2500016179,CDM,637,RC,6564930103,NDC,,,,,,outpatient,facility,200,UN,33.79,33.79,2.7,548.68,,23.96,,,percent of total billed charges,,,8.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,33.79,,,percent of total billed charges,,,21.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,23.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,23.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,33.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.37,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,33.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,33.79,,,fee schedule,,,33.79,,,percent of total billed charges,,,,,,,,,33.79,,,percent of total billed charges,,,20.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.08,,,percent of total billed charges,,,,,,,,,,,,,,,18.25,,,percent of total billed charges,,,17.57,,,percent of total billed charges,,,18.58,,,percent of total billed charges,,,,,,,,,19.94,,,percent of total billed charges,,,548.68,,,per diem,,,33.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,33.79,,,percent of total billed charges,,,28.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.95,,,percent of total billed charges,,,33.79,,,percent of total billed charges,,,33.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.79,,,percent of total billed charges,,,27.34,,,percent of total billed charges,,,,,,,,,,,,,,,13.52,,,percent of total billed charges,,,,,,,,,12.5,,,percent of total billed charges,,,12.5,,,percent of total billed charges,,,,,,,,,33.79,,,percent of total billed charges,,,33.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.7,,,percent of total billed charges,,,33.79,,,percent of total billed charges,,,,,,,,,,,,,,,33.79,,,percent of total billed charges,,,33.79,,,percent of total billed charges,,,,,,,,,31.43,,,percent of total billed charges,,,,,,,,,,,,,,,31.43,,,percent of total billed charges,,,31.43,,,percent of total billed charges,,,31.43,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,33.79,,,percent of total billed charges,,,33.79,,,percent of total billed charges,,,33.79,,,percent of total billed charges,,,,,,,,,23.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,19.91,,,percent of total billed charges,,
RIFAXIMIN 200 MG TAB,2500016179,CDM,637,RC,6564930103,NDC,999,EAPG,,,,outpatient,facility,200,UN,33.79,33.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RISPERIDONE 0.25 MG TAB,2500016230,CDM,637,RC,904635761,NDC,,,,,,inpatient,facility,0.25,UN,0.56,0.56,0.04,0.56,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,
RISPERIDONE 0.25 MG TAB,2500016230,CDM,637,RC,904635761,NDC,,,,,,outpatient,facility,0.25,UN,0.56,0.56,0.04,548.68,,0.4,,,percent of total billed charges,,,0.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,0.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.2,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.56,,,fee schedule,,,0.56,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,0.33,,,percent of total billed charges,,,548.68,,,per diem,,,0.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.56,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.33,,,percent of total billed charges,,
RISPERIDONE 0.25 MG TAB,2500016230,CDM,637,RC,904635761,NDC,999,EAPG,,,,outpatient,facility,0.25,UN,0.56,0.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RISPERIDONE 1 MG TAB,2500016232,CDM,637,RC,904635961,NDC,,,,,,inpatient,facility,1,UN,0.56,0.56,0.04,0.56,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,
RISPERIDONE 1 MG TAB,2500016232,CDM,637,RC,904635961,NDC,,,,,,outpatient,facility,1,UN,0.56,0.56,0.04,548.68,,0.4,,,percent of total billed charges,,,0.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.56,,,percent of total billed charges,,,0.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.2,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.56,,,fee schedule,,,0.56,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,0.33,,,percent of total billed charges,,,548.68,,,per diem,,,0.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.56,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,,,,,,,0.21,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.33,,,percent of total billed charges,,
RISPERIDONE 1 MG TAB,2500016232,CDM,637,RC,904635961,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.56,0.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RISPERIDONE 1 MG/ML SOL,2500016235,CDM,637,RC,6516267384,NDC,,,,,,inpatient,facility,1,UN,16.76,16.76,1.34,16.76,,,,,,,,,,,,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.76,,,percent of total billed charges,,,,,,,,,16.76,,,percent of total billed charges,,,8.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.06,,,percent of total billed charges,,,,,,,,,,,,,,,16.76,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,16.76,,,percent of total billed charges,,,8.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.87,,,percent of total billed charges,,
RISPERIDONE 1 MG/ML SOL,2500016235,CDM,637,RC,6516267384,NDC,,,,,,outpatient,facility,1,UN,16.76,16.76,1.34,548.68,,11.88,,,percent of total billed charges,,,4.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,16.76,,,percent of total billed charges,,,10.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,11.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,11.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.13,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,16.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,16.76,,,fee schedule,,,16.76,,,percent of total billed charges,,,,,,,,,16.76,,,percent of total billed charges,,,10.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.94,,,percent of total billed charges,,,,,,,,,,,,,,,9.05,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,9.22,,,percent of total billed charges,,,,,,,,,9.89,,,percent of total billed charges,,,548.68,,,per diem,,,16.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,16.76,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.9,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.31,,,percent of total billed charges,,,13.56,,,percent of total billed charges,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,,,,,,,6.2,,,percent of total billed charges,,,6.2,,,percent of total billed charges,,,,,,,,,16.76,,,percent of total billed charges,,,16.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.34,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,16.76,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,,,,,,,15.59,,,percent of total billed charges,,,,,,,,,,,,,,,15.59,,,percent of total billed charges,,,15.59,,,percent of total billed charges,,,15.59,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,,,,,,,11.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.87,,,percent of total billed charges,,
RISPERIDONE 1 MG/ML SOL,2500016235,CDM,637,RC,6516267384,NDC,999,EAPG,,,,outpatient,facility,1,UN,16.76,16.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIVAROXABAN 20 MG TAB,2500016254,CDM,637,RC,5045857910,NDC,,,,,,inpatient,facility,20,UN,62.67,62.67,5.01,62.67,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,62.67,,,percent of total billed charges,,,32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.6,,,percent of total billed charges,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,53.27,,,percent of total billed charges,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,33.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.93,,,percent of total billed charges,,
RIVAROXABAN 20 MG TAB,2500016254,CDM,637,RC,5045857910,NDC,,,,,,outpatient,facility,20,UN,62.67,62.67,5.01,548.68,,44.44,,,percent of total billed charges,,,15.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,62.67,,,percent of total billed charges,,,39.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,44.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,44.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,22.94,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,62.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,62.67,,,fee schedule,,,62.67,,,percent of total billed charges,,,,,,,,,62.67,,,percent of total billed charges,,,38.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.65,,,percent of total billed charges,,,,,,,,,,,,,,,33.84,,,percent of total billed charges,,,32.59,,,percent of total billed charges,,,34.47,,,percent of total billed charges,,,,,,,,,36.98,,,percent of total billed charges,,,548.68,,,per diem,,,62.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,62.67,,,percent of total billed charges,,,53.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.28,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.28,,,percent of total billed charges,,,50.71,,,percent of total billed charges,,,,,,,,,,,,,,,25.07,,,percent of total billed charges,,,,,,,,,23.19,,,percent of total billed charges,,,23.19,,,percent of total billed charges,,,,,,,,,62.67,,,percent of total billed charges,,,62.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,62.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.01,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,58.3,,,percent of total billed charges,,,,,,,,,,,,,,,58.3,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,47,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,43.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,36.93,,,percent of total billed charges,,
RIVAROXABAN 20 MG TAB,2500016254,CDM,637,RC,5045857910,NDC,999,EAPG,,,,outpatient,facility,20,UN,62.67,62.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIVAROXABAN 15 MG TAB,2500016258,CDM,637,RC,5045857810,NDC,,,,,,inpatient,facility,15,UN,62.67,62.67,5.01,62.67,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,62.67,,,percent of total billed charges,,,32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.6,,,percent of total billed charges,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,53.27,,,percent of total billed charges,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,33.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.93,,,percent of total billed charges,,
RIVAROXABAN 15 MG TAB,2500016258,CDM,637,RC,5045857810,NDC,,,,,,outpatient,facility,15,UN,62.67,62.67,5.01,548.68,,44.44,,,percent of total billed charges,,,15.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,62.67,,,percent of total billed charges,,,39.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,44.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,44.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,22.94,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,62.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,62.67,,,fee schedule,,,62.67,,,percent of total billed charges,,,,,,,,,62.67,,,percent of total billed charges,,,38.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.65,,,percent of total billed charges,,,,,,,,,,,,,,,33.84,,,percent of total billed charges,,,32.59,,,percent of total billed charges,,,34.47,,,percent of total billed charges,,,,,,,,,36.98,,,percent of total billed charges,,,548.68,,,per diem,,,62.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,62.67,,,percent of total billed charges,,,53.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.28,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.28,,,percent of total billed charges,,,50.71,,,percent of total billed charges,,,,,,,,,,,,,,,25.07,,,percent of total billed charges,,,,,,,,,23.19,,,percent of total billed charges,,,23.19,,,percent of total billed charges,,,,,,,,,62.67,,,percent of total billed charges,,,62.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,62.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.01,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,58.3,,,percent of total billed charges,,,,,,,,,,,,,,,58.3,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,47,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,43.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,36.93,,,percent of total billed charges,,
RIVAROXABAN 15 MG TAB,2500016258,CDM,637,RC,5045857810,NDC,999,EAPG,,,,outpatient,facility,15,UN,62.67,62.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIVAROXABAN 10 MG TAB,2500016259,CDM,637,RC,5045858010,NDC,,,,,,inpatient,facility,10,UN,62.67,62.67,5.01,62.67,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,62.67,,,percent of total billed charges,,,32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.6,,,percent of total billed charges,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,53.27,,,percent of total billed charges,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,33.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.93,,,percent of total billed charges,,
RIVAROXABAN 10 MG TAB,2500016259,CDM,637,RC,5045858010,NDC,,,,,,outpatient,facility,10,UN,62.67,62.67,5.01,548.68,,44.44,,,percent of total billed charges,,,15.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,62.67,,,percent of total billed charges,,,39.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,44.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,44.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,22.94,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,62.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,62.67,,,fee schedule,,,62.67,,,percent of total billed charges,,,,,,,,,62.67,,,percent of total billed charges,,,38.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.65,,,percent of total billed charges,,,,,,,,,,,,,,,33.84,,,percent of total billed charges,,,32.59,,,percent of total billed charges,,,34.47,,,percent of total billed charges,,,,,,,,,36.98,,,percent of total billed charges,,,548.68,,,per diem,,,62.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,62.67,,,percent of total billed charges,,,53.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.28,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.28,,,percent of total billed charges,,,50.71,,,percent of total billed charges,,,,,,,,,,,,,,,25.07,,,percent of total billed charges,,,,,,,,,23.19,,,percent of total billed charges,,,23.19,,,percent of total billed charges,,,,,,,,,62.67,,,percent of total billed charges,,,62.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,62.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.01,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,,,,,,,62.67,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,58.3,,,percent of total billed charges,,,,,,,,,,,,,,,58.3,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,47,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,62.67,,,percent of total billed charges,,,,,,,,,43.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,36.93,,,percent of total billed charges,,
RIVAROXABAN 10 MG TAB,2500016259,CDM,637,RC,5045858010,NDC,999,EAPG,,,,outpatient,facility,10,UN,62.67,62.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIVASTIGMINE TART 1.5 MG CAP,2500016260,CDM,637,RC,6586264860,NDC,,,,,,inpatient,facility,1.5,UN,15.37,15.37,1.23,15.37,,,,,,,,,,,,,,15.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.37,,,percent of total billed charges,,,,,,,,,15.37,,,percent of total billed charges,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.22,,,percent of total billed charges,,,,,,,,,,,,,,,15.37,,,percent of total billed charges,,,13.06,,,percent of total billed charges,,,,,,,,,,,,,,,15.37,,,percent of total billed charges,,,8.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,15.37,,,percent of total billed charges,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,15.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.06,,,percent of total billed charges,,
RIVASTIGMINE TART 1.5 MG CAP,2500016260,CDM,637,RC,6586264860,NDC,,,,,,outpatient,facility,1.5,UN,15.37,15.37,1.23,548.68,,10.9,,,percent of total billed charges,,,3.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,15.37,,,percent of total billed charges,,,9.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,15.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,15.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,15.37,,,fee schedule,,,15.37,,,percent of total billed charges,,,,,,,,,15.37,,,percent of total billed charges,,,9.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.95,,,percent of total billed charges,,,,,,,,,,,,,,,8.3,,,percent of total billed charges,,,7.99,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,9.07,,,percent of total billed charges,,,548.68,,,per diem,,,15.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,15.37,,,percent of total billed charges,,,13.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.16,,,percent of total billed charges,,,15.37,,,percent of total billed charges,,,15.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.37,,,percent of total billed charges,,,12.44,,,percent of total billed charges,,,,,,,,,,,,,,,6.15,,,percent of total billed charges,,,,,,,,,5.69,,,percent of total billed charges,,,5.69,,,percent of total billed charges,,,,,,,,,15.37,,,percent of total billed charges,,,15.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.23,,,percent of total billed charges,,,15.37,,,percent of total billed charges,,,,,,,,,,,,,,,15.37,,,percent of total billed charges,,,15.37,,,percent of total billed charges,,,,,,,,,14.3,,,percent of total billed charges,,,,,,,,,,,,,,,14.3,,,percent of total billed charges,,,14.3,,,percent of total billed charges,,,14.3,,,percent of total billed charges,,,11.53,,,percent of total billed charges,,,15.37,,,percent of total billed charges,,,15.37,,,percent of total billed charges,,,15.37,,,percent of total billed charges,,,,,,,,,10.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.06,,,percent of total billed charges,,
RIVASTIGMINE TART 1.5 MG CAP,2500016260,CDM,637,RC,6586264860,NDC,999,EAPG,,,,outpatient,facility,1.5,UN,15.37,15.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIVASTIGMINE 4.6 MG PATCH,2500016267,CDM,637,RC,4778130403,NDC,,,,,,inpatient,facility,1,UN,53.46,53.46,4.28,53.46,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,53.46,,,percent of total billed charges,,,27.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.08,,,percent of total billed charges,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,28.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.5,,,percent of total billed charges,,
RIVASTIGMINE 4.6 MG PATCH,2500016267,CDM,637,RC,4778130403,NDC,,,,,,outpatient,facility,1,UN,53.46,53.46,4.28,548.68,,37.91,,,percent of total billed charges,,,13.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,53.46,,,percent of total billed charges,,,33.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,37.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,37.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,19.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,53.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,53.46,,,fee schedule,,,53.46,,,percent of total billed charges,,,,,,,,,53.46,,,percent of total billed charges,,,32.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.09,,,percent of total billed charges,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,27.8,,,percent of total billed charges,,,29.4,,,percent of total billed charges,,,,,,,,,31.54,,,percent of total billed charges,,,548.68,,,per diem,,,53.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,53.46,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.39,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.06,,,percent of total billed charges,,,43.26,,,percent of total billed charges,,,,,,,,,,,,,,,21.38,,,percent of total billed charges,,,,,,,,,19.78,,,percent of total billed charges,,,19.78,,,percent of total billed charges,,,,,,,,,53.46,,,percent of total billed charges,,,53.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,53.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.28,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,49.73,,,percent of total billed charges,,,,,,,,,,,,,,,49.73,,,percent of total billed charges,,,49.73,,,percent of total billed charges,,,49.73,,,percent of total billed charges,,,40.09,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,37.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,31.5,,,percent of total billed charges,,
RIVASTIGMINE 4.6 MG PATCH,2500016267,CDM,637,RC,4778130403,NDC,999,EAPG,,,,outpatient,facility,1,UN,53.46,53.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIVASTIGMINE 9.5 MG PATCH,2500016268,CDM,637,RC,4778130503,NDC,,,,,,inpatient,facility,1,UN,53.46,53.46,4.28,53.46,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,53.46,,,percent of total billed charges,,,27.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.08,,,percent of total billed charges,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,28.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.5,,,percent of total billed charges,,
RIVASTIGMINE 9.5 MG PATCH,2500016268,CDM,637,RC,4778130503,NDC,,,,,,outpatient,facility,1,UN,53.46,53.46,4.28,548.68,,37.91,,,percent of total billed charges,,,13.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,53.46,,,percent of total billed charges,,,33.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,37.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,37.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,19.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,53.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,53.46,,,fee schedule,,,53.46,,,percent of total billed charges,,,,,,,,,53.46,,,percent of total billed charges,,,32.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.09,,,percent of total billed charges,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,27.8,,,percent of total billed charges,,,29.4,,,percent of total billed charges,,,,,,,,,31.54,,,percent of total billed charges,,,548.68,,,per diem,,,53.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,53.46,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.39,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.06,,,percent of total billed charges,,,43.26,,,percent of total billed charges,,,,,,,,,,,,,,,21.38,,,percent of total billed charges,,,,,,,,,19.78,,,percent of total billed charges,,,19.78,,,percent of total billed charges,,,,,,,,,53.46,,,percent of total billed charges,,,53.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,53.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.28,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,49.73,,,percent of total billed charges,,,,,,,,,,,,,,,49.73,,,percent of total billed charges,,,49.73,,,percent of total billed charges,,,49.73,,,percent of total billed charges,,,40.09,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,37.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,31.5,,,percent of total billed charges,,
RIVASTIGMINE 9.5 MG PATCH,2500016268,CDM,637,RC,4778130503,NDC,999,EAPG,,,,outpatient,facility,1,UN,53.46,53.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROCURONIUM 10 MG/ML 10 ML INJ,2500016274,CDM,250,RC,J3490,HCPCS,5515022610,NDC,,,,inpatient,facility,10,UN,66.33,66.33,5.31,66.33,,,,,,,,,,,,,,66.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.33,,,percent of total billed charges,,,,,,,,,66.33,,,percent of total billed charges,,,33.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.8,,,percent of total billed charges,,,,,,,,,,,,,,,66.33,,,percent of total billed charges,,,56.38,,,percent of total billed charges,,,,,,,,,,,,,,,66.33,,,percent of total billed charges,,,35.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,66.33,,,percent of total billed charges,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,66.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.08,,,percent of total billed charges,,
ROCURONIUM 10 MG/ML 10 ML INJ,2500016274,CDM,250,RC,J3490,HCPCS,5515022610,NDC,,,,outpatient,facility,10,UN,66.33,66.33,1.2,548.68,,47.03,,,percent of total billed charges,,,16.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,66.33,,,percent of total billed charges,,,41.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,46.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,46.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,66.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,24.28,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,66.33,,,fee schedule,,,66.33,,,percent of total billed charges,,,,,,,,,66.33,,,percent of total billed charges,,,40.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.26,,,percent of total billed charges,,,,,,,,,,,,,,,66.33,,,percent of total billed charges,,,66.33,,,percent of total billed charges,,,66.33,,,percent of total billed charges,,,,,,,,,39.13,,,percent of total billed charges,,,548.68,,,per diem,,,66.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,66.33,,,percent of total billed charges,,,56.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.23,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.75,,,percent of total billed charges,,,53.67,,,percent of total billed charges,,,,,,,,,,,,,,,26.53,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,66.33,,,percent of total billed charges,,,66.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,66.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.31,,,percent of total billed charges,,,66.33,,,percent of total billed charges,,,,,,,,,,,,,,,66.33,,,percent of total billed charges,,,66.33,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,49.75,,,percent of total billed charges,,,66.33,,,percent of total billed charges,,,66.33,,,percent of total billed charges,,,66.33,,,percent of total billed charges,,,,,,,,,46.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,39.08,,,percent of total billed charges,,
ROCURONIUM 10 MG/ML 10 ML INJ,2500016274,CDM,250,RC,J3490,HCPCS,5515022610,NDC,435,EAPG,,outpatient,facility,10,UN,66.33,66.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROCURONIUM 10 MG/ML 5 ML INJ,2500016275,CDM,250,RC,J3490,HCPCS,6332342605,NDC,,,,inpatient,facility,100,UN,34.65,34.65,2.77,34.65,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,34.65,,,percent of total billed charges,,,17.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,29.45,,,percent of total billed charges,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,18.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.42,,,percent of total billed charges,,
ROCURONIUM 10 MG/ML 5 ML INJ,2500016275,CDM,250,RC,J3490,HCPCS,6332342605,NDC,,,,outpatient,facility,100,UN,34.65,34.65,1.2,548.68,,24.57,,,percent of total billed charges,,,8.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,34.65,,,percent of total billed charges,,,21.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,24.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,24.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.68,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,34.65,,,fee schedule,,,34.65,,,percent of total billed charges,,,,,,,,,34.65,,,percent of total billed charges,,,21.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.69,,,percent of total billed charges,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,20.44,,,percent of total billed charges,,,548.68,,,per diem,,,34.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,34.65,,,percent of total billed charges,,,29.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.4,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.37,,,percent of total billed charges,,,28.04,,,percent of total billed charges,,,,,,,,,,,,,,,13.86,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,34.65,,,percent of total billed charges,,,34.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,34.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.77,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,25.99,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,,,,,,,24.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,20.42,,,percent of total billed charges,,
ROCURONIUM 10 MG/ML 5 ML INJ,2500016275,CDM,250,RC,J3490,HCPCS,6332342605,NDC,435,EAPG,,outpatient,facility,100,UN,34.65,34.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROFLUMILAST 500 MCG TAB,2500016286,CDM,637,RC,310009530,NDC,,,,,,inpatient,facility,500,UN,48.81,48.81,3.9,48.81,,,,,,,,,,,,,,48.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.81,,,percent of total billed charges,,,,,,,,,48.81,,,percent of total billed charges,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.29,,,percent of total billed charges,,,,,,,,,,,,,,,48.81,,,percent of total billed charges,,,41.49,,,percent of total billed charges,,,,,,,,,,,,,,,48.81,,,percent of total billed charges,,,25.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,48.81,,,percent of total billed charges,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,48.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.76,,,percent of total billed charges,,
ROFLUMILAST 500 MCG TAB,2500016286,CDM,637,RC,310009530,NDC,,,,,,outpatient,facility,500,UN,48.81,48.81,3.9,548.68,,34.61,,,percent of total billed charges,,,11.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,48.81,,,percent of total billed charges,,,30.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,34.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,34.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,48.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,17.86,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,48.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,48.81,,,fee schedule,,,48.81,,,percent of total billed charges,,,,,,,,,48.81,,,percent of total billed charges,,,29.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.78,,,percent of total billed charges,,,,,,,,,,,,,,,26.36,,,percent of total billed charges,,,25.38,,,percent of total billed charges,,,26.85,,,percent of total billed charges,,,,,,,,,28.8,,,percent of total billed charges,,,548.68,,,per diem,,,48.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,48.81,,,percent of total billed charges,,,41.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.92,,,percent of total billed charges,,,48.81,,,percent of total billed charges,,,48.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.93,,,percent of total billed charges,,,39.5,,,percent of total billed charges,,,,,,,,,,,,,,,19.52,,,percent of total billed charges,,,,,,,,,18.06,,,percent of total billed charges,,,18.06,,,percent of total billed charges,,,,,,,,,48.81,,,percent of total billed charges,,,48.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,48.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.9,,,percent of total billed charges,,,48.81,,,percent of total billed charges,,,,,,,,,,,,,,,48.81,,,percent of total billed charges,,,48.81,,,percent of total billed charges,,,,,,,,,45.4,,,percent of total billed charges,,,,,,,,,,,,,,,45.4,,,percent of total billed charges,,,45.4,,,percent of total billed charges,,,45.4,,,percent of total billed charges,,,36.61,,,percent of total billed charges,,,48.81,,,percent of total billed charges,,,48.81,,,percent of total billed charges,,,48.81,,,percent of total billed charges,,,,,,,,,34.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,28.76,,,percent of total billed charges,,
ROFLUMILAST 500 MCG TAB,2500016286,CDM,637,RC,310009530,NDC,999,EAPG,,,,outpatient,facility,500,UN,48.81,48.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROPINIROLE HCL 0.25 MG TAB,2500016290,CDM,637,RC,4354726810,NDC,,,,,,inpatient,facility,0.25,UN,8.25,8.25,0.66,8.25,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,8.25,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,7.01,,,percent of total billed charges,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.86,,,percent of total billed charges,,
ROPINIROLE HCL 0.25 MG TAB,2500016290,CDM,637,RC,4354726810,NDC,,,,,,outpatient,facility,0.25,UN,8.25,8.25,0.66,548.68,,5.85,,,percent of total billed charges,,,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.25,,,percent of total billed charges,,,5.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.02,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.25,,,fee schedule,,,8.25,,,percent of total billed charges,,,,,,,,,8.25,,,percent of total billed charges,,,5.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.88,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,4.29,,,percent of total billed charges,,,4.54,,,percent of total billed charges,,,,,,,,,4.87,,,percent of total billed charges,,,548.68,,,per diem,,,8.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.25,,,percent of total billed charges,,,7.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.38,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,6.68,,,percent of total billed charges,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,3.05,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,,,,,,,8.25,,,percent of total billed charges,,,8.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.66,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,7.67,,,percent of total billed charges,,,,,,,,,,,,,,,7.67,,,percent of total billed charges,,,7.67,,,percent of total billed charges,,,7.67,,,percent of total billed charges,,,6.19,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.86,,,percent of total billed charges,,
ROPINIROLE HCL 0.25 MG TAB,2500016290,CDM,637,RC,4354726810,NDC,999,EAPG,,,,outpatient,facility,0.25,UN,8.25,8.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROPINIROLE HCL 1 MG TAB,2500016291,CDM,637,RC,4354727010,NDC,,,,,,inpatient,facility,1,UN,8.25,8.25,0.66,8.25,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,8.25,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,7.01,,,percent of total billed charges,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.86,,,percent of total billed charges,,
ROPINIROLE HCL 1 MG TAB,2500016291,CDM,637,RC,4354727010,NDC,,,,,,outpatient,facility,1,UN,8.25,8.25,0.66,548.68,,5.85,,,percent of total billed charges,,,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.25,,,percent of total billed charges,,,5.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.02,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.25,,,fee schedule,,,8.25,,,percent of total billed charges,,,,,,,,,8.25,,,percent of total billed charges,,,5.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.88,,,percent of total billed charges,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,4.29,,,percent of total billed charges,,,4.54,,,percent of total billed charges,,,,,,,,,4.87,,,percent of total billed charges,,,548.68,,,per diem,,,8.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.25,,,percent of total billed charges,,,7.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.38,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,6.68,,,percent of total billed charges,,,,,,,,,,,,,,,3.3,,,percent of total billed charges,,,,,,,,,3.05,,,percent of total billed charges,,,3.05,,,percent of total billed charges,,,,,,,,,8.25,,,percent of total billed charges,,,8.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.66,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,7.67,,,percent of total billed charges,,,,,,,,,,,,,,,7.67,,,percent of total billed charges,,,7.67,,,percent of total billed charges,,,7.67,,,percent of total billed charges,,,6.19,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.86,,,percent of total billed charges,,
ROPINIROLE HCL 1 MG TAB,2500016291,CDM,637,RC,4354727010,NDC,999,EAPG,,,,outpatient,facility,1,UN,8.25,8.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROPIVACAINE HCL 40 MG,2500016300,CDM,636,RC,J2795,HCPCS,5515019520,NDC,,,,inpatient,facility,20,UN,53.46,53.46,4.28,53.46,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,53.46,,,percent of total billed charges,,,27.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.08,,,percent of total billed charges,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,28.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.5,,,percent of total billed charges,,
ROPIVACAINE HCL 40 MG,2500016300,CDM,636,RC,J2795,HCPCS,5515019520,NDC,,,,outpatient,facility,20,UN,53.46,53.46,0.08,548.68,,37.91,,,percent of total billed charges,,,13.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,53.46,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,19.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,53.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,53.46,,,fee schedule,,,53.46,,,percent of total billed charges,,,,,,,,,53.46,,,percent of total billed charges,,,32.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,31.54,,,percent of total billed charges,,,548.68,,,per diem,,,53.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,53.46,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.39,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.06,,,percent of total billed charges,,,43.26,,,percent of total billed charges,,,,,,,,,,,,,,,21.38,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,53.46,,,percent of total billed charges,,,53.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,53.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.28,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.08,,,fee schedule,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,,,,,,,37.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,31.5,,,percent of total billed charges,,
ROPIVACAINE HCL 40 MG,2500016300,CDM,636,RC,J2795,HCPCS,5515019520,NDC,496,EAPG,,outpatient,facility,20,UN,53.46,53.46,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SALIVA SUBSTITUTE 45 GM TUBE,2500016352,CDM,637,RC,4858251201,NDC,,,,,,inpatient,facility,42,UN,7.07,7.07,0.57,7.07,,,,,,,,,,,,,,7.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.07,,,percent of total billed charges,,,,,,,,,7.07,,,percent of total billed charges,,,3.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.24,,,percent of total billed charges,,,,,,,,,,,,,,,7.07,,,percent of total billed charges,,,6.01,,,percent of total billed charges,,,,,,,,,,,,,,,7.07,,,percent of total billed charges,,,3.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.07,,,percent of total billed charges,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,7.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.17,,,percent of total billed charges,,
SALIVA SUBSTITUTE 45 GM TUBE,2500016352,CDM,637,RC,4858251201,NDC,,,,,,outpatient,facility,42,UN,7.07,7.07,0.57,548.68,,5.01,,,percent of total billed charges,,,1.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.07,,,percent of total billed charges,,,4.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.59,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.07,,,fee schedule,,,7.07,,,percent of total billed charges,,,,,,,,,7.07,,,percent of total billed charges,,,4.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.04,,,percent of total billed charges,,,,,,,,,,,,,,,3.82,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,3.89,,,percent of total billed charges,,,,,,,,,4.17,,,percent of total billed charges,,,548.68,,,per diem,,,7.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.07,,,percent of total billed charges,,,6.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.75,,,percent of total billed charges,,,7.07,,,percent of total billed charges,,,7.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.77,,,percent of total billed charges,,,5.72,,,percent of total billed charges,,,,,,,,,,,,,,,2.83,,,percent of total billed charges,,,,,,,,,2.62,,,percent of total billed charges,,,2.62,,,percent of total billed charges,,,,,,,,,7.07,,,percent of total billed charges,,,7.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.57,,,percent of total billed charges,,,7.07,,,percent of total billed charges,,,,,,,,,,,,,,,7.07,,,percent of total billed charges,,,7.07,,,percent of total billed charges,,,,,,,,,6.58,,,percent of total billed charges,,,,,,,,,,,,,,,6.58,,,percent of total billed charges,,,6.58,,,percent of total billed charges,,,6.58,,,percent of total billed charges,,,5.3,,,percent of total billed charges,,,7.07,,,percent of total billed charges,,,7.07,,,percent of total billed charges,,,7.07,,,percent of total billed charges,,,,,,,,,4.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.17,,,percent of total billed charges,,
SALIVA SUBSTITUTE 45 GM TUBE,2500016352,CDM,637,RC,4858251201,NDC,999,EAPG,,,,outpatient,facility,42,UN,7.07,7.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SELEGILINE HCL 5 MG CAP,2500016430,CDM,637,RC,6050500551,NDC,,,,,,inpatient,facility,5,UN,7.59,7.59,0.61,7.59,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,7.59,,,percent of total billed charges,,,3.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,6.45,,,percent of total billed charges,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.47,,,percent of total billed charges,,
SELEGILINE HCL 5 MG CAP,2500016430,CDM,637,RC,6050500551,NDC,,,,,,outpatient,facility,5,UN,7.59,7.59,0.61,548.68,,5.38,,,percent of total billed charges,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.59,,,percent of total billed charges,,,4.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.78,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.59,,,fee schedule,,,7.59,,,percent of total billed charges,,,,,,,,,7.59,,,percent of total billed charges,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,4.1,,,percent of total billed charges,,,3.95,,,percent of total billed charges,,,4.17,,,percent of total billed charges,,,,,,,,,4.48,,,percent of total billed charges,,,548.68,,,per diem,,,7.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.59,,,percent of total billed charges,,,6.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,2.81,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,7.59,,,percent of total billed charges,,,7.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.61,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,7.06,,,percent of total billed charges,,,,,,,,,,,,,,,7.06,,,percent of total billed charges,,,7.06,,,percent of total billed charges,,,7.06,,,percent of total billed charges,,,5.69,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,7.59,,,percent of total billed charges,,,,,,,,,5.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.79,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.47,,,percent of total billed charges,,
SELEGILINE HCL 5 MG CAP,2500016430,CDM,637,RC,6050500551,NDC,999,EAPG,,,,outpatient,facility,5,UN,7.59,7.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SENNA 187 MG TAB,2500016470,CDM,637,RC,904652261,NDC,,,,,,inpatient,facility,8.6,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
SENNA 187 MG TAB,2500016470,CDM,637,RC,904652261,NDC,,,,,,outpatient,facility,8.6,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
SENNA 187 MG TAB,2500016470,CDM,637,RC,904652261,NDC,999,EAPG,,,,outpatient,facility,8.6,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SERTRALINE HCL 25 MG TAB,2500016481,CDM,637,RC,6586201105,NDC,,,,,,inpatient,facility,25,UN,9.4,9.4,0.75,9.4,,,,,,,,,,,,,,9.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.4,,,percent of total billed charges,,,,,,,,,9.4,,,percent of total billed charges,,,4.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,9.4,,,percent of total billed charges,,,7.99,,,percent of total billed charges,,,,,,,,,,,,,,,9.4,,,percent of total billed charges,,,4.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,9.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.54,,,percent of total billed charges,,
SERTRALINE HCL 25 MG TAB,2500016481,CDM,637,RC,6586201105,NDC,,,,,,outpatient,facility,25,UN,9.4,9.4,0.75,548.68,,6.67,,,percent of total billed charges,,,2.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.4,,,percent of total billed charges,,,5.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.4,,,fee schedule,,,9.4,,,percent of total billed charges,,,,,,,,,9.4,,,percent of total billed charges,,,5.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.7,,,percent of total billed charges,,,,,,,,,,,,,,,5.08,,,percent of total billed charges,,,4.89,,,percent of total billed charges,,,5.17,,,percent of total billed charges,,,,,,,,,5.55,,,percent of total billed charges,,,548.68,,,per diem,,,9.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.4,,,percent of total billed charges,,,7.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.99,,,percent of total billed charges,,,9.4,,,percent of total billed charges,,,9.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,7.61,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,3.48,,,percent of total billed charges,,,3.48,,,percent of total billed charges,,,,,,,,,9.4,,,percent of total billed charges,,,9.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.75,,,percent of total billed charges,,,9.4,,,percent of total billed charges,,,,,,,,,,,,,,,9.4,,,percent of total billed charges,,,9.4,,,percent of total billed charges,,,,,,,,,8.74,,,percent of total billed charges,,,,,,,,,,,,,,,8.74,,,percent of total billed charges,,,8.74,,,percent of total billed charges,,,8.74,,,percent of total billed charges,,,7.05,,,percent of total billed charges,,,9.4,,,percent of total billed charges,,,9.4,,,percent of total billed charges,,,9.4,,,percent of total billed charges,,,,,,,,,6.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.54,,,percent of total billed charges,,
SERTRALINE HCL 25 MG TAB,2500016481,CDM,637,RC,6586201105,NDC,999,EAPG,,,,outpatient,facility,25,UN,9.4,9.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SERTRALINE HCL 50 MG TAB,2500016482,CDM,637,RC,904692561,NDC,,,,,,inpatient,facility,50,UN,1.32,1.32,0.11,1.32,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,
SERTRALINE HCL 50 MG TAB,2500016482,CDM,637,RC,904692561,NDC,,,,,,outpatient,facility,50,UN,1.32,1.32,0.11,548.68,,0.94,,,percent of total billed charges,,,0.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.32,,,percent of total billed charges,,,0.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.48,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.32,,,fee schedule,,,1.32,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,0.78,,,percent of total billed charges,,,548.68,,,per diem,,,1.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.32,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,1.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.78,,,percent of total billed charges,,
SERTRALINE HCL 50 MG TAB,2500016482,CDM,637,RC,904692561,NDC,999,EAPG,,,,outpatient,facility,50,UN,1.32,1.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SILVER  NITR SWABS,2500016530,CDM,637,RC,1287000011,NDC,,,,,,inpatient,facility,1,UN,2.5,2.5,0.2,2.5,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,2.5,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,
SILVER  NITR SWABS,2500016530,CDM,637,RC,1287000011,NDC,,,,,,outpatient,facility,1,UN,2.5,2.5,0.2,548.68,,1.77,,,percent of total billed charges,,,0.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.5,,,percent of total billed charges,,,1.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.92,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.5,,,fee schedule,,,2.5,,,percent of total billed charges,,,,,,,,,2.5,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,1.48,,,percent of total billed charges,,,548.68,,,per diem,,,2.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.5,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,0.93,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,2.5,,,percent of total billed charges,,,2.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,,,,,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.47,,,percent of total billed charges,,
SILVER  NITR SWABS,2500016530,CDM,637,RC,1287000011,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.5,2.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SILVER SULFADIAZINE 1  CR 400G,2500016542,CDM,637,RC,6787712440,NDC,,,,,,inpatient,facility,400,UN,214.34,214.34,17.15,214.34,,,,,,,,,,,,,,214.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.34,,,percent of total billed charges,,,,,,,,,214.34,,,percent of total billed charges,,,109.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.6,,,percent of total billed charges,,,,,,,,,,,,,,,214.34,,,percent of total billed charges,,,182.19,,,percent of total billed charges,,,,,,,,,,,,,,,214.34,,,percent of total billed charges,,,113.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,214.34,,,percent of total billed charges,,,,,,,,,,,,,,,17.15,,,percent of total billed charges,,,214.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,214.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.29,,,percent of total billed charges,,
SILVER SULFADIAZINE 1  CR 400G,2500016542,CDM,637,RC,6787712440,NDC,,,,,,outpatient,facility,400,UN,214.34,214.34,17.15,548.68,,151.99,,,percent of total billed charges,,,52.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,214.34,,,percent of total billed charges,,,134.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,150.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,150.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,214.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,78.45,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,214.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,214.34,,,fee schedule,,,214.34,,,percent of total billed charges,,,,,,,,,214.34,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.72,,,percent of total billed charges,,,,,,,,,,,,,,,115.74,,,percent of total billed charges,,,111.46,,,percent of total billed charges,,,117.89,,,percent of total billed charges,,,,,,,,,126.46,,,percent of total billed charges,,,548.68,,,per diem,,,214.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,214.34,,,percent of total billed charges,,,182.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.84,,,percent of total billed charges,,,214.34,,,percent of total billed charges,,,214.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.59,,,percent of total billed charges,,,173.44,,,percent of total billed charges,,,,,,,,,,,,,,,85.74,,,percent of total billed charges,,,,,,,,,79.31,,,percent of total billed charges,,,79.31,,,percent of total billed charges,,,,,,,,,214.34,,,percent of total billed charges,,,214.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,214.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.15,,,percent of total billed charges,,,214.34,,,percent of total billed charges,,,,,,,,,,,,,,,214.34,,,percent of total billed charges,,,214.34,,,percent of total billed charges,,,,,,,,,199.38,,,percent of total billed charges,,,,,,,,,,,,,,,199.38,,,percent of total billed charges,,,199.38,,,percent of total billed charges,,,199.38,,,percent of total billed charges,,,160.75,,,percent of total billed charges,,,214.34,,,percent of total billed charges,,,214.34,,,percent of total billed charges,,,214.34,,,percent of total billed charges,,,,,,,,,150.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.17,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,126.29,,,percent of total billed charges,,
SILVER SULFADIAZINE 1  CR 400G,2500016542,CDM,637,RC,6787712440,NDC,999,EAPG,,,,outpatient,facility,400,UN,214.34,214.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SILVER SULFADIAZINE 1  CR 50GM,2500016543,CDM,637,RC,6787712405,NDC,,,,,,inpatient,facility,50,UN,49.9,49.9,3.99,49.9,,,,,,,,,,,,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.9,,,percent of total billed charges,,,,,,,,,49.9,,,percent of total billed charges,,,25.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.94,,,percent of total billed charges,,,,,,,,,,,,,,,49.9,,,percent of total billed charges,,,42.42,,,percent of total billed charges,,,,,,,,,,,,,,,49.9,,,percent of total billed charges,,,26.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,3.99,,,percent of total billed charges,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.4,,,percent of total billed charges,,
SILVER SULFADIAZINE 1  CR 50GM,2500016543,CDM,637,RC,6787712405,NDC,,,,,,outpatient,facility,50,UN,49.9,49.9,3.99,548.68,,35.38,,,percent of total billed charges,,,12.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,49.9,,,percent of total billed charges,,,31.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,35.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,35.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,18.26,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,49.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,49.9,,,fee schedule,,,49.9,,,percent of total billed charges,,,,,,,,,49.9,,,percent of total billed charges,,,30.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.55,,,percent of total billed charges,,,,,,,,,,,,,,,26.95,,,percent of total billed charges,,,25.95,,,percent of total billed charges,,,27.45,,,percent of total billed charges,,,,,,,,,29.44,,,percent of total billed charges,,,548.68,,,per diem,,,49.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,49.9,,,percent of total billed charges,,,42.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.5,,,percent of total billed charges,,,49.9,,,percent of total billed charges,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,,,,,,,,,,,,,19.96,,,percent of total billed charges,,,,,,,,,18.46,,,percent of total billed charges,,,18.46,,,percent of total billed charges,,,,,,,,,49.9,,,percent of total billed charges,,,49.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,49.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.99,,,percent of total billed charges,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,49.9,,,percent of total billed charges,,,49.9,,,percent of total billed charges,,,,,,,,,46.42,,,percent of total billed charges,,,,,,,,,,,,,,,46.42,,,percent of total billed charges,,,46.42,,,percent of total billed charges,,,46.42,,,percent of total billed charges,,,37.42,,,percent of total billed charges,,,49.9,,,percent of total billed charges,,,49.9,,,percent of total billed charges,,,49.9,,,percent of total billed charges,,,,,,,,,34.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,29.4,,,percent of total billed charges,,
SILVER SULFADIAZINE 1  CR 50GM,2500016543,CDM,637,RC,6787712405,NDC,999,EAPG,,,,outpatient,facility,50,UN,49.9,49.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIMETHICONE 80 MG CHEW TAB,2500016550,CDM,637,RC,5789679101,NDC,,,,,,inpatient,facility,80,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
SIMETHICONE 80 MG CHEW TAB,2500016550,CDM,637,RC,5789679101,NDC,,,,,,outpatient,facility,80,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
SIMETHICONE 80 MG CHEW TAB,2500016550,CDM,637,RC,5789679101,NDC,999,EAPG,,,,outpatient,facility,80,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIMETHICONE 40 MG/0.6 ML 30 ML,2500016553,CDM,637,RC,536130375,NDC,,,,,,inpatient,facility,30,UN,51.02,51.02,4.08,51.02,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,51.02,,,percent of total billed charges,,,26.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.61,,,percent of total billed charges,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,43.37,,,percent of total billed charges,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,27.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,4.08,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.06,,,percent of total billed charges,,
SIMETHICONE 40 MG/0.6 ML 30 ML,2500016553,CDM,637,RC,536130375,NDC,,,,,,outpatient,facility,30,UN,51.02,51.02,4.08,548.68,,36.18,,,percent of total billed charges,,,12.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,51.02,,,percent of total billed charges,,,31.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,35.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,35.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,18.67,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,51.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,51.02,,,fee schedule,,,51.02,,,percent of total billed charges,,,,,,,,,51.02,,,percent of total billed charges,,,31.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.35,,,percent of total billed charges,,,,,,,,,,,,,,,27.55,,,percent of total billed charges,,,26.53,,,percent of total billed charges,,,28.06,,,percent of total billed charges,,,,,,,,,30.1,,,percent of total billed charges,,,548.68,,,per diem,,,51.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,51.02,,,percent of total billed charges,,,43.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.1,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.42,,,percent of total billed charges,,,41.29,,,percent of total billed charges,,,,,,,,,,,,,,,20.41,,,percent of total billed charges,,,,,,,,,18.88,,,percent of total billed charges,,,18.88,,,percent of total billed charges,,,,,,,,,51.02,,,percent of total billed charges,,,51.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,51.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.08,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,,,,,,,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,47.46,,,percent of total billed charges,,,,,,,,,,,,,,,47.46,,,percent of total billed charges,,,47.46,,,percent of total billed charges,,,47.46,,,percent of total billed charges,,,38.27,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,51.02,,,percent of total billed charges,,,,,,,,,35.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,30.06,,,percent of total billed charges,,
SIMETHICONE 40 MG/0.6 ML 30 ML,2500016553,CDM,637,RC,536130375,NDC,999,EAPG,,,,outpatient,facility,30,UN,51.02,51.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SIMETHICONE 20 MG/0.3 ML UD,2500016554,CDM,637,RC,6237263015,NDC,,,,,,inpatient,facility,0.3,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
SIMETHICONE 20 MG/0.3 ML UD,2500016554,CDM,637,RC,6237263015,NDC,,,,,,outpatient,facility,0.3,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
SIMETHICONE 20 MG/0.3 ML UD,2500016554,CDM,637,RC,6237263015,NDC,999,EAPG,,,,outpatient,facility,0.3,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THEOPHYLLINE 100 MG CAPCR,2500016600,CDM,637,RC,5224410010,NDC,,,,,,inpatient,facility,100,UN,11.61,11.61,0.93,11.61,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,,,,,,,11.61,,,percent of total billed charges,,,5.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.97,,,percent of total billed charges,,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,9.87,,,percent of total billed charges,,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,6.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.84,,,percent of total billed charges,,
THEOPHYLLINE 100 MG CAPCR,2500016600,CDM,637,RC,5224410010,NDC,,,,,,outpatient,facility,100,UN,11.61,11.61,0.93,548.68,,8.23,,,percent of total billed charges,,,2.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,11.61,,,percent of total billed charges,,,7.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,11.61,,,fee schedule,,,11.61,,,percent of total billed charges,,,,,,,,,11.61,,,percent of total billed charges,,,7.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.27,,,percent of total billed charges,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,6.04,,,percent of total billed charges,,,6.39,,,percent of total billed charges,,,,,,,,,6.85,,,percent of total billed charges,,,548.68,,,per diem,,,11.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11.61,,,percent of total billed charges,,,9.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.17,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.83,,,percent of total billed charges,,,9.39,,,percent of total billed charges,,,,,,,,,,,,,,,4.64,,,percent of total billed charges,,,,,,,,,4.3,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,,,,,,,11.61,,,percent of total billed charges,,,11.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.93,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,,,,,,,,,,,,,11.61,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,,,,,,,10.8,,,percent of total billed charges,,,,,,,,,,,,,,,10.8,,,percent of total billed charges,,,10.8,,,percent of total billed charges,,,10.8,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,,,,,,,8.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.84,,,percent of total billed charges,,
THEOPHYLLINE 100 MG CAPCR,2500016600,CDM,637,RC,5224410010,NDC,999,EAPG,,,,outpatient,facility,100,UN,11.61,11.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD PHOS/BIPHOS ENEMA 133 ML,2500016620,CDM,637,RC,536741551,NDC,,,,,,inpatient,facility,133,UN,2.16,2.16,0.17,2.16,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,2.16,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,
SOD PHOS/BIPHOS ENEMA 133 ML,2500016620,CDM,637,RC,536741551,NDC,,,,,,outpatient,facility,133,UN,2.16,2.16,0.17,548.68,,1.53,,,percent of total billed charges,,,0.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.16,,,percent of total billed charges,,,1.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.79,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.16,,,fee schedule,,,2.16,,,percent of total billed charges,,,,,,,,,2.16,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,1.27,,,percent of total billed charges,,,548.68,,,per diem,,,2.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.16,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.46,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,0.8,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,2.16,,,percent of total billed charges,,,2.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.08,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.27,,,percent of total billed charges,,
SOD PHOS/BIPHOS ENEMA 133 ML,2500016620,CDM,637,RC,536741551,NDC,999,EAPG,,,,outpatient,facility,133,UN,2.16,2.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD POLYSTYRENE 30 GM/120 ML,2500016630,CDM,637,RC,4628700604,NDC,,,,,,inpatient,facility,120,UN,447.48,447.48,35.8,447.48,,,,,,,,,,,,,,447.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.48,,,percent of total billed charges,,,,,,,,,447.48,,,percent of total billed charges,,,228.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,381.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,268.49,,,percent of total billed charges,,,,,,,,,,,,,,,447.48,,,percent of total billed charges,,,380.36,,,percent of total billed charges,,,,,,,,,,,,,,,447.48,,,percent of total billed charges,,,237.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,447.48,,,percent of total billed charges,,,,,,,,,,,,,,,35.8,,,percent of total billed charges,,,447.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,447.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.66,,,percent of total billed charges,,
SOD POLYSTYRENE 30 GM/120 ML,2500016630,CDM,637,RC,4628700604,NDC,,,,,,outpatient,facility,120,UN,447.48,447.48,35.8,548.68,,317.31,,,percent of total billed charges,,,109.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,447.48,,,percent of total billed charges,,,280.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,314.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,314.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,447.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,163.78,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,447.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,447.48,,,fee schedule,,,447.48,,,percent of total billed charges,,,,,,,,,447.48,,,percent of total billed charges,,,274.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.83,,,percent of total billed charges,,,,,,,,,,,,,,,241.64,,,percent of total billed charges,,,232.69,,,percent of total billed charges,,,246.11,,,percent of total billed charges,,,,,,,,,264.01,,,percent of total billed charges,,,548.68,,,per diem,,,447.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,447.48,,,percent of total billed charges,,,380.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,237.66,,,percent of total billed charges,,,447.48,,,percent of total billed charges,,,447.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.87,,,percent of total billed charges,,,362.1,,,percent of total billed charges,,,,,,,,,,,,,,,178.99,,,percent of total billed charges,,,,,,,,,165.57,,,percent of total billed charges,,,165.57,,,percent of total billed charges,,,,,,,,,447.48,,,percent of total billed charges,,,447.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,447.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.8,,,percent of total billed charges,,,447.48,,,percent of total billed charges,,,,,,,,,,,,,,,447.48,,,percent of total billed charges,,,447.48,,,percent of total billed charges,,,,,,,,,416.25,,,percent of total billed charges,,,,,,,,,,,,,,,416.25,,,percent of total billed charges,,,416.25,,,percent of total billed charges,,,416.25,,,percent of total billed charges,,,335.61,,,percent of total billed charges,,,447.48,,,percent of total billed charges,,,447.48,,,percent of total billed charges,,,447.48,,,percent of total billed charges,,,,,,,,,313.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,263.66,,,percent of total billed charges,,
SOD POLYSTYRENE 30 GM/120 ML,2500016630,CDM,637,RC,4628700604,NDC,999,EAPG,,,,outpatient,facility,120,UN,447.48,447.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD POLYSTYRENE 15 GM/60 ML UD,2500016632,CDM,637,RC,4628700660,NDC,,,,,,inpatient,facility,60,UN,102.3,102.3,8.18,102.3,,,,,,,,,,,,,,102.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.3,,,percent of total billed charges,,,,,,,,,102.3,,,percent of total billed charges,,,52.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,,,,,,,,,,,,,102.3,,,percent of total billed charges,,,86.96,,,percent of total billed charges,,,,,,,,,,,,,,,102.3,,,percent of total billed charges,,,54.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,102.3,,,percent of total billed charges,,,,,,,,,,,,,,,8.18,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,102.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.28,,,percent of total billed charges,,
SOD POLYSTYRENE 15 GM/60 ML UD,2500016632,CDM,637,RC,4628700660,NDC,,,,,,outpatient,facility,60,UN,102.3,102.3,8.18,548.68,,72.54,,,percent of total billed charges,,,24.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,102.3,,,percent of total billed charges,,,64.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,71.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,71.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,102.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,37.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,102.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,102.3,,,fee schedule,,,102.3,,,percent of total billed charges,,,,,,,,,102.3,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.89,,,percent of total billed charges,,,,,,,,,,,,,,,55.24,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,56.27,,,percent of total billed charges,,,,,,,,,60.36,,,percent of total billed charges,,,548.68,,,per diem,,,102.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,102.3,,,percent of total billed charges,,,86.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.33,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.01,,,percent of total billed charges,,,82.78,,,percent of total billed charges,,,,,,,,,,,,,,,40.92,,,percent of total billed charges,,,,,,,,,37.85,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,,,,,,,102.3,,,percent of total billed charges,,,102.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,102.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.18,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,,,,,,,,,,,,,102.3,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,,,,,,,95.16,,,percent of total billed charges,,,,,,,,,,,,,,,95.16,,,percent of total billed charges,,,95.16,,,percent of total billed charges,,,95.16,,,percent of total billed charges,,,76.72,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,,,,,,,71.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.15,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,60.28,,,percent of total billed charges,,
SOD POLYSTYRENE 15 GM/60 ML UD,2500016632,CDM,637,RC,4628700660,NDC,999,EAPG,,,,outpatient,facility,60,UN,102.3,102.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD ACETATE 2 MEQ/ML 20 ML INJ,2500016640,CDM,250,RC,J3490,HCPCS,409729973,NDC,,,,inpatient,facility,20,UN,10.56,10.56,0.84,10.56,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,10.56,,,percent of total billed charges,,,5.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.22,,,percent of total billed charges,,
SOD ACETATE 2 MEQ/ML 20 ML INJ,2500016640,CDM,250,RC,J3490,HCPCS,409729973,NDC,,,,outpatient,facility,20,UN,10.56,10.56,0.84,548.68,,7.49,,,percent of total billed charges,,,2.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.56,,,percent of total billed charges,,,6.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.86,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,10.56,,,fee schedule,,,10.56,,,percent of total billed charges,,,,,,,,,10.56,,,percent of total billed charges,,,6.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.52,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,6.23,,,percent of total billed charges,,,548.68,,,per diem,,,10.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.56,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.12,,,percent of total billed charges,,,8.55,,,percent of total billed charges,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,10.56,,,percent of total billed charges,,,10.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.84,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,7.92,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.22,,,percent of total billed charges,,
SOD ACETATE 2 MEQ/ML 20 ML INJ,2500016640,CDM,250,RC,J3490,HCPCS,409729973,NDC,435,EAPG,,outpatient,facility,20,UN,10.56,10.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD BICARB 2.4MEQ/5ML INJ,2500016653,CDM,250,RC,409555502,NDC,,,,,,inpatient,facility,5,UN,25.54,25.54,2.04,25.54,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,25.54,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.32,,,percent of total billed charges,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,21.71,,,percent of total billed charges,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,13.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.05,,,percent of total billed charges,,
SOD BICARB 2.4MEQ/5ML INJ,2500016653,CDM,250,RC,409555502,NDC,,,,,,outpatient,facility,5,UN,25.54,25.54,2.04,548.68,,18.11,,,percent of total billed charges,,,6.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,25.54,,,percent of total billed charges,,,16.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,17.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,17.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.35,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,25.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,25.54,,,fee schedule,,,25.54,,,percent of total billed charges,,,,,,,,,25.54,,,percent of total billed charges,,,15.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,15.07,,,percent of total billed charges,,,548.68,,,per diem,,,25.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,25.54,,,percent of total billed charges,,,21.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.56,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.23,,,percent of total billed charges,,,20.67,,,percent of total billed charges,,,,,,,,,,,,,,,10.22,,,percent of total billed charges,,,,,,,,,10.22,,,percent of total billed charges,,,10.22,,,percent of total billed charges,,,,,,,,,25.54,,,percent of total billed charges,,,25.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.04,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,10.22,,,percent of total billed charges,,,,,,,,,,,,,,,10.22,,,percent of total billed charges,,,10.22,,,percent of total billed charges,,,10.22,,,percent of total billed charges,,,19.16,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,25.54,,,percent of total billed charges,,,,,,,,,17.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15.05,,,percent of total billed charges,,
SOD BICARB 2.4MEQ/5ML INJ,2500016653,CDM,250,RC,409555502,NDC,999,EAPG,,,,outpatient,facility,5,UN,25.54,25.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD BICARB 4.2  10 ML SYR,2500016655,CDM,250,RC,409553424,NDC,,,,,,inpatient,facility,10,UN,24.42,24.42,1.95,24.42,,,,,,,,,,,,,,24.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.42,,,percent of total billed charges,,,,,,,,,24.42,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.65,,,percent of total billed charges,,,,,,,,,,,,,,,24.42,,,percent of total billed charges,,,20.76,,,percent of total billed charges,,,,,,,,,,,,,,,24.42,,,percent of total billed charges,,,12.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,24.42,,,percent of total billed charges,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,24.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.39,,,percent of total billed charges,,
SOD BICARB 4.2  10 ML SYR,2500016655,CDM,250,RC,409553424,NDC,,,,,,outpatient,facility,10,UN,24.42,24.42,1.95,548.68,,17.32,,,percent of total billed charges,,,5.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,24.42,,,percent of total billed charges,,,15.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,17.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,17.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,24.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.94,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,24.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,24.42,,,fee schedule,,,24.42,,,percent of total billed charges,,,,,,,,,24.42,,,percent of total billed charges,,,14.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,14.41,,,percent of total billed charges,,,548.68,,,per diem,,,24.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,24.42,,,percent of total billed charges,,,20.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.97,,,percent of total billed charges,,,24.42,,,percent of total billed charges,,,24.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.47,,,percent of total billed charges,,,19.76,,,percent of total billed charges,,,,,,,,,,,,,,,9.77,,,percent of total billed charges,,,,,,,,,9.77,,,percent of total billed charges,,,9.77,,,percent of total billed charges,,,,,,,,,24.42,,,percent of total billed charges,,,24.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.95,,,percent of total billed charges,,,24.42,,,percent of total billed charges,,,,,,,,,,,,,,,24.42,,,percent of total billed charges,,,24.42,,,percent of total billed charges,,,,,,,,,9.77,,,percent of total billed charges,,,,,,,,,,,,,,,9.77,,,percent of total billed charges,,,9.77,,,percent of total billed charges,,,9.77,,,percent of total billed charges,,,18.32,,,percent of total billed charges,,,24.42,,,percent of total billed charges,,,24.42,,,percent of total billed charges,,,24.42,,,percent of total billed charges,,,,,,,,,17.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.39,,,percent of total billed charges,,
SOD BICARB 4.2  10 ML SYR,2500016655,CDM,250,RC,409553424,NDC,999,EAPG,,,,outpatient,facility,10,UN,24.42,24.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD BICARB 8.4  50 ML SYR,2500016657,CDM,250,RC,J3490,HCPCS,409663714,NDC,,,,inpatient,facility,50,UN,63.29,63.29,5.06,63.29,,,,,,,,,,,,,,63.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.29,,,percent of total billed charges,,,,,,,,,63.29,,,percent of total billed charges,,,32.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.97,,,percent of total billed charges,,,,,,,,,,,,,,,63.29,,,percent of total billed charges,,,53.8,,,percent of total billed charges,,,,,,,,,,,,,,,63.29,,,percent of total billed charges,,,33.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,63.29,,,percent of total billed charges,,,,,,,,,,,,,,,5.06,,,percent of total billed charges,,,63.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.29,,,percent of total billed charges,,
SOD BICARB 8.4  50 ML SYR,2500016657,CDM,250,RC,J3490,HCPCS,409663714,NDC,,,,outpatient,facility,50,UN,63.29,63.29,1.2,548.68,,44.88,,,percent of total billed charges,,,15.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,63.29,,,percent of total billed charges,,,39.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,44.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,44.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,63.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,23.16,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,63.29,,,fee schedule,,,63.29,,,percent of total billed charges,,,,,,,,,63.29,,,percent of total billed charges,,,38.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.09,,,percent of total billed charges,,,,,,,,,,,,,,,63.29,,,percent of total billed charges,,,63.29,,,percent of total billed charges,,,63.29,,,percent of total billed charges,,,,,,,,,37.34,,,percent of total billed charges,,,548.68,,,per diem,,,63.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,63.29,,,percent of total billed charges,,,53.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.61,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.7,,,percent of total billed charges,,,51.21,,,percent of total billed charges,,,,,,,,,,,,,,,25.32,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,63.29,,,percent of total billed charges,,,63.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,63.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.06,,,percent of total billed charges,,,63.29,,,percent of total billed charges,,,,,,,,,,,,,,,63.29,,,percent of total billed charges,,,63.29,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,47.47,,,percent of total billed charges,,,63.29,,,percent of total billed charges,,,63.29,,,percent of total billed charges,,,63.29,,,percent of total billed charges,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,37.29,,,percent of total billed charges,,
SOD BICARB 8.4  50 ML SYR,2500016657,CDM,250,RC,J3490,HCPCS,409663714,NDC,435,EAPG,,outpatient,facility,50,UN,63.29,63.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD BICARB 8.4  50 ML INJ,2500016658,CDM,250,RC,6332308950,NDC,,,,,,inpatient,facility,50,UN,28.87,28.87,2.31,28.87,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,,,,,,,28.87,,,percent of total billed charges,,,14.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.32,,,percent of total billed charges,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,24.54,,,percent of total billed charges,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,15.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.01,,,percent of total billed charges,,
SOD BICARB 8.4  50 ML INJ,2500016658,CDM,250,RC,6332308950,NDC,,,,,,outpatient,facility,50,UN,28.87,28.87,2.31,548.68,,20.47,,,percent of total billed charges,,,7.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,28.87,,,percent of total billed charges,,,18.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,20.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,20.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,28.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,28.87,,,fee schedule,,,28.87,,,percent of total billed charges,,,,,,,,,28.87,,,percent of total billed charges,,,17.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,17.03,,,percent of total billed charges,,,548.68,,,per diem,,,28.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,28.87,,,percent of total billed charges,,,24.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.33,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.48,,,percent of total billed charges,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,,,,,,,28.87,,,percent of total billed charges,,,28.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.31,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,,,,,,,,,,,,,28.87,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,11.55,,,percent of total billed charges,,,21.65,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,28.87,,,percent of total billed charges,,,,,,,,,20.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.01,,,percent of total billed charges,,
SOD BICARB 8.4  50 ML INJ,2500016658,CDM,250,RC,6332308950,NDC,999,EAPG,,,,outpatient,facility,50,UN,28.87,28.87,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD BICARB 8.4  10 ML SYR,2500016659,CDM,250,RC,6332308950,NDC,,,,,,inpatient,facility,10,UN,14.39,14.39,1.15,14.39,,,,,,,,,,,,,,14.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.39,,,percent of total billed charges,,,,,,,,,14.39,,,percent of total billed charges,,,7.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.63,,,percent of total billed charges,,,,,,,,,,,,,,,14.39,,,percent of total billed charges,,,12.23,,,percent of total billed charges,,,,,,,,,,,,,,,14.39,,,percent of total billed charges,,,7.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.39,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,14.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.48,,,percent of total billed charges,,
SOD BICARB 8.4  10 ML SYR,2500016659,CDM,250,RC,6332308950,NDC,,,,,,outpatient,facility,10,UN,14.39,14.39,1.15,548.68,,10.2,,,percent of total billed charges,,,3.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.39,,,percent of total billed charges,,,9.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.27,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.39,,,fee schedule,,,14.39,,,percent of total billed charges,,,,,,,,,14.39,,,percent of total billed charges,,,8.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,8.49,,,percent of total billed charges,,,548.68,,,per diem,,,14.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.39,,,percent of total billed charges,,,12.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,14.39,,,percent of total billed charges,,,14.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.71,,,percent of total billed charges,,,11.64,,,percent of total billed charges,,,,,,,,,,,,,,,5.76,,,percent of total billed charges,,,,,,,,,5.76,,,percent of total billed charges,,,5.76,,,percent of total billed charges,,,,,,,,,14.39,,,percent of total billed charges,,,14.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.15,,,percent of total billed charges,,,14.39,,,percent of total billed charges,,,,,,,,,,,,,,,14.39,,,percent of total billed charges,,,14.39,,,percent of total billed charges,,,,,,,,,5.76,,,percent of total billed charges,,,,,,,,,,,,,,,5.76,,,percent of total billed charges,,,5.76,,,percent of total billed charges,,,5.76,,,percent of total billed charges,,,10.79,,,percent of total billed charges,,,14.39,,,percent of total billed charges,,,14.39,,,percent of total billed charges,,,14.39,,,percent of total billed charges,,,,,,,,,10.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.48,,,percent of total billed charges,,
SOD BICARB 8.4  10 ML SYR,2500016659,CDM,250,RC,6332308950,NDC,999,EAPG,,,,outpatient,facility,10,UN,14.39,14.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD BICARB 650 MG TAB,2500016660,CDM,637,RC,7733383110,NDC,,,,,,inpatient,facility,650,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
SOD BICARB 650 MG TAB,2500016660,CDM,637,RC,7733383110,NDC,,,,,,outpatient,facility,650,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
SOD BICARB 650 MG TAB,2500016660,CDM,637,RC,7733383110,NDC,999,EAPG,,,,outpatient,facility,650,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.9  GEL,2500016677,CDM,637,RC,592800099,NDC,,,,,,inpatient,facility,30,UN,12.66,12.66,1.01,12.66,,,,,,,,,,,,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.66,,,percent of total billed charges,,,,,,,,,12.66,,,percent of total billed charges,,,6.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,12.66,,,percent of total billed charges,,,10.76,,,percent of total billed charges,,,,,,,,,,,,,,,12.66,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.46,,,percent of total billed charges,,
SOD CHLORIDE 0.9  GEL,2500016677,CDM,637,RC,592800099,NDC,,,,,,outpatient,facility,30,UN,12.66,12.66,1.01,548.68,,8.98,,,percent of total billed charges,,,3.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,12.66,,,percent of total billed charges,,,7.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,12.66,,,fee schedule,,,12.66,,,percent of total billed charges,,,,,,,,,12.66,,,percent of total billed charges,,,7.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.02,,,percent of total billed charges,,,,,,,,,,,,,,,6.84,,,percent of total billed charges,,,6.58,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,,,,,,,7.47,,,percent of total billed charges,,,548.68,,,per diem,,,12.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12.66,,,percent of total billed charges,,,10.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.72,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.54,,,percent of total billed charges,,,10.24,,,percent of total billed charges,,,,,,,,,,,,,,,5.06,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,12.66,,,percent of total billed charges,,,12.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.01,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,12.66,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,,,,,,,11.78,,,percent of total billed charges,,,,,,,,,,,,,,,11.78,,,percent of total billed charges,,,11.78,,,percent of total billed charges,,,11.78,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,,,,,,,8.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.33,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.46,,,percent of total billed charges,,
SOD CHLORIDE 0.9  GEL,2500016677,CDM,637,RC,592800099,NDC,999,EAPG,,,,outpatient,facility,30,UN,12.66,12.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.65  NASAL 45ML,2500016683,CDM,637,RC,904386575,NDC,,,,,,inpatient,facility,45,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
SOD CHLORIDE 0.65  NASAL 45ML,2500016683,CDM,637,RC,904386575,NDC,,,,,,outpatient,facility,45,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
SOD CHLORIDE 0.65  NASAL 45ML,2500016683,CDM,637,RC,904386575,NDC,999,EAPG,,,,outpatient,facility,45,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.9  3 ML INHA,2500016685,CDM,637,RC,J7699,HCPCS,487930103,NDC,,,,inpatient,facility,3,UN,0.99,0.99,0.08,0.99,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
SOD CHLORIDE 0.9  3 ML INHA,2500016685,CDM,637,RC,J7699,HCPCS,487930103,NDC,,,,outpatient,facility,3,UN,0.99,0.99,0.08,548.68,,0.7,,,percent of total billed charges,,,0.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.99,,,percent of total billed charges,,,0.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,0.99,,,fee schedule,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.58,,,percent of total billed charges,,,548.68,,,per diem,,,0.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.99,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,0.37,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
SOD CHLORIDE 0.9  3 ML INHA,2500016685,CDM,637,RC,J7699,HCPCS,487930103,NDC,435,EAPG,,outpatient,facility,3,UN,0.99,0.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.9  IRR 500 ML,2500016687,CDM,258,RC,264220110,NDC,,,,,,inpatient,facility,500,UN,16.5,16.5,1.32,16.5,,,,,,,,,,,,,,16.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.5,,,percent of total billed charges,,,,,,,,,16.5,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,16.5,,,percent of total billed charges,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,16.5,,,percent of total billed charges,,,8.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,16.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,16.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.72,,,percent of total billed charges,,
SOD CHLORIDE 0.9  IRR 500 ML,2500016687,CDM,258,RC,264220110,NDC,,,,,,outpatient,facility,500,UN,16.5,16.5,1.32,548.68,,11.7,,,percent of total billed charges,,,4.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,16.5,,,percent of total billed charges,,,10.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,11.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,11.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.04,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,16.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,16.5,,,fee schedule,,,16.5,,,percent of total billed charges,,,,,,,,,16.5,,,percent of total billed charges,,,10.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,9.74,,,percent of total billed charges,,,548.68,,,per diem,,,16.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,16.5,,,percent of total billed charges,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.76,,,percent of total billed charges,,,16.5,,,percent of total billed charges,,,16.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.13,,,percent of total billed charges,,,13.35,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,16.5,,,percent of total billed charges,,,16.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.32,,,percent of total billed charges,,,16.5,,,percent of total billed charges,,,,,,,,,,,,,,,16.5,,,percent of total billed charges,,,16.5,,,percent of total billed charges,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,12.38,,,percent of total billed charges,,,16.5,,,percent of total billed charges,,,16.5,,,percent of total billed charges,,,16.5,,,percent of total billed charges,,,,,,,,,11.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.72,,,percent of total billed charges,,
SOD CHLORIDE 0.9  IRR 500 ML,2500016687,CDM,258,RC,264220110,NDC,999,EAPG,,,,outpatient,facility,500,UN,16.5,16.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 1 GM TAB,2500016690,CDM,637,RC,6936722001,NDC,,,,,,inpatient,facility,1,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
SOD CHLORIDE 1 GM TAB,2500016690,CDM,637,RC,6936722001,NDC,,,,,,outpatient,facility,1,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
SOD CHLORIDE 1 GM TAB,2500016690,CDM,637,RC,6936722001,NDC,999,EAPG,,,,outpatient,facility,1,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 23.4  30 ML INJ,2500016693,CDM,250,RC,409114102,NDC,,,,,,inpatient,facility,10,UN,2.21,2.21,0.18,2.21,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,
SOD CHLORIDE 23.4  30 ML INJ,2500016693,CDM,250,RC,409114102,NDC,,,,,,outpatient,facility,10,UN,2.21,2.21,0.18,548.68,,1.57,,,percent of total billed charges,,,0.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.21,,,percent of total billed charges,,,1.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.81,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.21,,,fee schedule,,,2.21,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,1.3,,,percent of total billed charges,,,548.68,,,per diem,,,2.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.21,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,0.88,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,2.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,0.88,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.3,,,percent of total billed charges,,
SOD CHLORIDE 23.4  30 ML INJ,2500016693,CDM,250,RC,409114102,NDC,999,EAPG,,,,outpatient,facility,10,UN,2.21,2.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 3  500 ML,2500016695,CDM,636,RC,J7131,HCPCS,6332353075,NDC,,,,inpatient,facility,500,UN,13.2,13.2,1.06,13.2,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,6.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,11.22,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,7.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.78,,,percent of total billed charges,,
SOD CHLORIDE 3  500 ML,2500016695,CDM,636,RC,J7131,HCPCS,6332353075,NDC,,,,outpatient,facility,500,UN,13.2,13.2,1.06,548.68,,9.36,,,percent of total billed charges,,,3.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.83,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,13.2,,,fee schedule,,,13.2,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.79,,,percent of total billed charges,,,548.68,,,per diem,,,13.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.2,,,percent of total billed charges,,,11.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.01,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.9,,,percent of total billed charges,,,10.68,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13.2,,,percent of total billed charges,,,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.06,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,9.9,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,,,,,,,9.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.78,,,percent of total billed charges,,
SOD CHLORIDE 3  500 ML,2500016695,CDM,636,RC,J7131,HCPCS,6332353075,NDC,496,EAPG,,outpatient,facility,500,UN,13.2,13.2,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 5  OPH 15 ML,2500016702,CDM,637,RC,536125494,NDC,,,,,,inpatient,facility,15,UN,6.57,6.57,0.53,6.57,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,,,,,,,6.57,,,percent of total billed charges,,,3.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.94,,,percent of total billed charges,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,5.58,,,percent of total billed charges,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,3.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,
SOD CHLORIDE 5  OPH 15 ML,2500016702,CDM,637,RC,536125494,NDC,,,,,,outpatient,facility,15,UN,6.57,6.57,0.53,548.68,,4.66,,,percent of total billed charges,,,1.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.57,,,percent of total billed charges,,,4.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.57,,,fee schedule,,,6.57,,,percent of total billed charges,,,,,,,,,6.57,,,percent of total billed charges,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,3.55,,,percent of total billed charges,,,3.42,,,percent of total billed charges,,,3.61,,,percent of total billed charges,,,,,,,,,3.88,,,percent of total billed charges,,,548.68,,,per diem,,,6.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.57,,,percent of total billed charges,,,5.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.49,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.43,,,percent of total billed charges,,,5.32,,,percent of total billed charges,,,,,,,,,,,,,,,2.63,,,percent of total billed charges,,,,,,,,,2.43,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,,,,,,,6.57,,,percent of total billed charges,,,6.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.53,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,,,,,,,6.11,,,percent of total billed charges,,,,,,,,,,,,,,,6.11,,,percent of total billed charges,,,6.11,,,percent of total billed charges,,,6.11,,,percent of total billed charges,,,4.93,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,,,,,,,4.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.87,,,percent of total billed charges,,
SOD CHLORIDE 5  OPH 15 ML,2500016702,CDM,637,RC,536125494,NDC,999,EAPG,,,,outpatient,facility,15,UN,6.57,6.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 3  NEB 15 ML,2500016705,CDM,637,RC,378699789,NDC,,,,,,inpatient,facility,15,UN,2.48,2.48,0.2,2.48,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,2.48,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.46,,,percent of total billed charges,,
SOD CHLORIDE 3  NEB 15 ML,2500016705,CDM,637,RC,378699789,NDC,,,,,,outpatient,facility,15,UN,2.48,2.48,0.2,548.68,,1.76,,,percent of total billed charges,,,0.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.48,,,percent of total billed charges,,,1.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.48,,,fee schedule,,,2.48,,,percent of total billed charges,,,,,,,,,2.48,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,1.46,,,percent of total billed charges,,,548.68,,,per diem,,,2.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.48,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,2.48,,,percent of total billed charges,,,2.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.46,,,percent of total billed charges,,
SOD CHLORIDE 3  NEB 15 ML,2500016705,CDM,637,RC,378699789,NDC,999,EAPG,,,,outpatient,facility,15,UN,2.48,2.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.9 IRR 3000 ML,2500016707,CDM,258,RC,990797208,NDC,,,,,,inpatient,facility,3000,UN,99,99,7.92,99,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,99,,,percent of total billed charges,,,50.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,,percent of total billed charges,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,84.15,,,percent of total billed charges,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,52.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.33,,,percent of total billed charges,,
SOD CHLORIDE 0.9 IRR 3000 ML,2500016707,CDM,258,RC,990797208,NDC,,,,,,outpatient,facility,3000,UN,99,99,7.92,548.68,,70.2,,,percent of total billed charges,,,24.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,99,,,percent of total billed charges,,,62.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,69.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,69.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,36.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,99,,,fee schedule,,,99,,,percent of total billed charges,,,,,,,,,99,,,percent of total billed charges,,,60.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,58.41,,,percent of total billed charges,,,548.68,,,per diem,,,99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,99,,,percent of total billed charges,,,84.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.58,,,percent of total billed charges,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.79,,,percent of total billed charges,,,80.11,,,percent of total billed charges,,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,,,,,,,39.6,,,percent of total billed charges,,,39.6,,,percent of total billed charges,,,,,,,,,99,,,percent of total billed charges,,,99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.92,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,39.6,,,percent of total billed charges,,,39.6,,,percent of total billed charges,,,39.6,,,percent of total billed charges,,,74.25,,,percent of total billed charges,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,,,,,,,69.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,58.33,,,percent of total billed charges,,
SOD CHLORIDE 0.9 IRR 3000 ML,2500016707,CDM,258,RC,990797208,NDC,999,EAPG,,,,outpatient,facility,3000,UN,99,99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD HYPOCHLORITE 1/2 480ML,2500016732,CDM,250,RC,3932806325,NDC,,,,,,inpatient,facility,480,UN,26.64,26.64,2.13,26.64,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,,,,,,,26.64,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.98,,,percent of total billed charges,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,22.64,,,percent of total billed charges,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,14.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.7,,,percent of total billed charges,,
SOD HYPOCHLORITE 1/2 480ML,2500016732,CDM,250,RC,3932806325,NDC,,,,,,outpatient,facility,480,UN,26.64,26.64,2.13,548.68,,18.89,,,percent of total billed charges,,,6.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,26.64,,,percent of total billed charges,,,16.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,18.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,18.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.75,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,26.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,26.64,,,fee schedule,,,26.64,,,percent of total billed charges,,,,,,,,,26.64,,,percent of total billed charges,,,16.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,15.72,,,percent of total billed charges,,,548.68,,,per diem,,,26.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,26.64,,,percent of total billed charges,,,22.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.97,,,percent of total billed charges,,,21.56,,,percent of total billed charges,,,,,,,,,,,,,,,10.66,,,percent of total billed charges,,,,,,,,,10.66,,,percent of total billed charges,,,10.66,,,percent of total billed charges,,,,,,,,,26.64,,,percent of total billed charges,,,26.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.13,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,,,,,,,10.66,,,percent of total billed charges,,,,,,,,,,,,,,,10.66,,,percent of total billed charges,,,10.66,,,percent of total billed charges,,,10.66,,,percent of total billed charges,,,19.98,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,,,,,,,18.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15.7,,,percent of total billed charges,,
SOD HYPOCHLORITE 1/2 480ML,2500016732,CDM,250,RC,3932806325,NDC,999,EAPG,,,,outpatient,facility,480,UN,26.64,26.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD HYPOCHLORITE 1/4 480ML,2500016738,CDM,250,RC,3932806412,NDC,,,,,,inpatient,facility,480,UN,26.64,26.64,2.13,26.64,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,,,,,,,26.64,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.98,,,percent of total billed charges,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,22.64,,,percent of total billed charges,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,14.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.7,,,percent of total billed charges,,
SOD HYPOCHLORITE 1/4 480ML,2500016738,CDM,250,RC,3932806412,NDC,,,,,,outpatient,facility,480,UN,26.64,26.64,2.13,548.68,,18.89,,,percent of total billed charges,,,6.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,26.64,,,percent of total billed charges,,,16.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,18.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,18.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.75,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,26.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,26.64,,,fee schedule,,,26.64,,,percent of total billed charges,,,,,,,,,26.64,,,percent of total billed charges,,,16.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,15.72,,,percent of total billed charges,,,548.68,,,per diem,,,26.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,26.64,,,percent of total billed charges,,,22.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.97,,,percent of total billed charges,,,21.56,,,percent of total billed charges,,,,,,,,,,,,,,,10.66,,,percent of total billed charges,,,,,,,,,10.66,,,percent of total billed charges,,,10.66,,,percent of total billed charges,,,,,,,,,26.64,,,percent of total billed charges,,,26.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.13,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,,,,,,,,,,,,,26.64,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,,,,,,,10.66,,,percent of total billed charges,,,,,,,,,,,,,,,10.66,,,percent of total billed charges,,,10.66,,,percent of total billed charges,,,10.66,,,percent of total billed charges,,,19.98,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,26.64,,,percent of total billed charges,,,,,,,,,18.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15.7,,,percent of total billed charges,,
SOD HYPOCHLORITE 1/4 480ML,2500016738,CDM,250,RC,3932806412,NDC,999,EAPG,,,,outpatient,facility,480,UN,26.64,26.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD PHOSPHATE 3 MM/ML 15ML INJ,2500016753,CDM,250,RC,409739172,NDC,,,,,,inpatient,facility,15,UN,60.32,60.32,4.83,60.32,,,,,,,,,,,,,,60.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.32,,,percent of total billed charges,,,,,,,,,60.32,,,percent of total billed charges,,,30.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.19,,,percent of total billed charges,,,,,,,,,,,,,,,60.32,,,percent of total billed charges,,,51.27,,,percent of total billed charges,,,,,,,,,,,,,,,60.32,,,percent of total billed charges,,,32.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,60.32,,,percent of total billed charges,,,,,,,,,,,,,,,4.83,,,percent of total billed charges,,,60.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.54,,,percent of total billed charges,,
SOD PHOSPHATE 3 MM/ML 15ML INJ,2500016753,CDM,250,RC,409739172,NDC,,,,,,outpatient,facility,15,UN,60.32,60.32,4.83,548.68,,42.77,,,percent of total billed charges,,,14.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,60.32,,,percent of total billed charges,,,37.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,42.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,42.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,60.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,22.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,60.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,60.32,,,fee schedule,,,60.32,,,percent of total billed charges,,,,,,,,,60.32,,,percent of total billed charges,,,36.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,35.59,,,percent of total billed charges,,,548.68,,,per diem,,,60.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,60.32,,,percent of total billed charges,,,51.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.04,,,percent of total billed charges,,,60.32,,,percent of total billed charges,,,60.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.69,,,percent of total billed charges,,,48.81,,,percent of total billed charges,,,,,,,,,,,,,,,24.13,,,percent of total billed charges,,,,,,,,,24.13,,,percent of total billed charges,,,24.13,,,percent of total billed charges,,,,,,,,,60.32,,,percent of total billed charges,,,60.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,60.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.83,,,percent of total billed charges,,,60.32,,,percent of total billed charges,,,,,,,,,,,,,,,60.32,,,percent of total billed charges,,,60.32,,,percent of total billed charges,,,,,,,,,24.13,,,percent of total billed charges,,,,,,,,,,,,,,,24.13,,,percent of total billed charges,,,24.13,,,percent of total billed charges,,,24.13,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,60.32,,,percent of total billed charges,,,60.32,,,percent of total billed charges,,,60.32,,,percent of total billed charges,,,,,,,,,42.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,35.54,,,percent of total billed charges,,
SOD PHOSPHATE 3 MM/ML 15ML INJ,2500016753,CDM,250,RC,409739172,NDC,999,EAPG,,,,outpatient,facility,15,UN,60.32,60.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD TETRADECYL 3  2 ML AMP,2500016763,CDM,250,RC,2420120105,NDC,,,,,,inpatient,facility,2,UN,254.1,254.1,20.33,254.1,,,,,,,,,,,,,,254.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.1,,,percent of total billed charges,,,,,,,,,254.1,,,percent of total billed charges,,,129.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,216.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.46,,,percent of total billed charges,,,,,,,,,,,,,,,254.1,,,percent of total billed charges,,,215.98,,,percent of total billed charges,,,,,,,,,,,,,,,254.1,,,percent of total billed charges,,,134.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,254.1,,,percent of total billed charges,,,,,,,,,,,,,,,20.33,,,percent of total billed charges,,,254.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,254.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.72,,,percent of total billed charges,,
SOD TETRADECYL 3  2 ML AMP,2500016763,CDM,250,RC,2420120105,NDC,,,,,,outpatient,facility,2,UN,254.1,254.1,20.33,548.68,,180.18,,,percent of total billed charges,,,62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,254.1,,,percent of total billed charges,,,159.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,178.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,178.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,254.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,93,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,254.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,254.1,,,fee schedule,,,254.1,,,percent of total billed charges,,,,,,,,,254.1,,,percent of total billed charges,,,155.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,149.92,,,percent of total billed charges,,,548.68,,,per diem,,,254.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,254.1,,,percent of total billed charges,,,215.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,134.95,,,percent of total billed charges,,,254.1,,,percent of total billed charges,,,254.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.42,,,percent of total billed charges,,,205.62,,,percent of total billed charges,,,,,,,,,,,,,,,101.64,,,percent of total billed charges,,,,,,,,,101.64,,,percent of total billed charges,,,101.64,,,percent of total billed charges,,,,,,,,,254.1,,,percent of total billed charges,,,254.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,254.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.33,,,percent of total billed charges,,,254.1,,,percent of total billed charges,,,,,,,,,,,,,,,254.1,,,percent of total billed charges,,,254.1,,,percent of total billed charges,,,,,,,,,101.64,,,percent of total billed charges,,,,,,,,,,,,,,,101.64,,,percent of total billed charges,,,101.64,,,percent of total billed charges,,,101.64,,,percent of total billed charges,,,190.57,,,percent of total billed charges,,,254.1,,,percent of total billed charges,,,254.1,,,percent of total billed charges,,,254.1,,,percent of total billed charges,,,,,,,,,178.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,149.72,,,percent of total billed charges,,
SOD TETRADECYL 3  2 ML AMP,2500016763,CDM,250,RC,2420120105,NDC,999,EAPG,,,,outpatient,facility,2,UN,254.1,254.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD THIOSULF 25  50 ML INJ,2500016772,CDM,250,RC,J0209,HCPCS,6026770550,NDC,,,,inpatient,facility,50,UN,353.1,353.1,28.25,353.1,,,,,,,,,,,,,,353.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,353.1,,,percent of total billed charges,,,,,,,,,353.1,,,percent of total billed charges,,,180.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,300.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.86,,,percent of total billed charges,,,,,,,,,,,,,,,353.1,,,percent of total billed charges,,,300.14,,,percent of total billed charges,,,,,,,,,,,,,,,353.1,,,percent of total billed charges,,,187.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,353.1,,,percent of total billed charges,,,,,,,,,,,,,,,28.25,,,percent of total billed charges,,,353.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,353.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,208.05,,,percent of total billed charges,,
SOD THIOSULF 25  50 ML INJ,2500016772,CDM,250,RC,J0209,HCPCS,6026770550,NDC,,,,outpatient,facility,50,UN,353.1,353.1,1.08,548.68,,250.38,,,percent of total billed charges,,,86.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,353.1,,,percent of total billed charges,,,1.14,,,fee schedule,,,1.08,,,fee schedule,,,,,,,,,1.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,353.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,129.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,353.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,353.1,,,fee schedule,,,353.1,,,percent of total billed charges,,,,,,,,,353.1,,,percent of total billed charges,,,216.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,251.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,208.33,,,percent of total billed charges,,,548.68,,,per diem,,,353.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,353.1,,,percent of total billed charges,,,300.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,187.53,,,percent of total billed charges,,,353.1,,,percent of total billed charges,,,353.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.2,,,percent of total billed charges,,,285.73,,,percent of total billed charges,,,,,,,,,,,,,,,141.24,,,percent of total billed charges,,,,,,,,,130.65,,,percent of total billed charges,,,130.65,,,percent of total billed charges,,,,,,,,,353.1,,,percent of total billed charges,,,353.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,353.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.25,,,percent of total billed charges,,,353.1,,,percent of total billed charges,,,,,,,,,,,,,,,353.1,,,percent of total billed charges,,,353.1,,,percent of total billed charges,,,,,,,,,328.45,,,percent of total billed charges,,,,,,,,,,,,,,,328.45,,,percent of total billed charges,,,328.45,,,percent of total billed charges,,,328.45,,,percent of total billed charges,,,264.83,,,percent of total billed charges,,,353.1,,,percent of total billed charges,,,353.1,,,percent of total billed charges,,,353.1,,,percent of total billed charges,,,,,,,,,247.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,208.05,,,percent of total billed charges,,
SOD THIOSULF 25  50 ML INJ,2500016772,CDM,250,RC,J0209,HCPCS,6026770550,NDC,999,EAPG,,outpatient,facility,50,UN,353.1,353.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOTALOL HCL 80 MG TAB,2500016794,CDM,637,RC,6050500800,NDC,,,,,,inpatient,facility,80,UN,8.45,8.45,0.68,8.45,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,8.45,,,percent of total billed charges,,,4.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,7.18,,,percent of total billed charges,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,4.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.98,,,percent of total billed charges,,
SOTALOL HCL 80 MG TAB,2500016794,CDM,637,RC,6050500800,NDC,,,,,,outpatient,facility,80,UN,8.45,8.45,0.68,548.68,,5.99,,,percent of total billed charges,,,2.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.45,,,percent of total billed charges,,,5.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.09,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.45,,,fee schedule,,,8.45,,,percent of total billed charges,,,,,,,,,8.45,,,percent of total billed charges,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,,4.56,,,percent of total billed charges,,,4.39,,,percent of total billed charges,,,4.65,,,percent of total billed charges,,,,,,,,,4.99,,,percent of total billed charges,,,548.68,,,per diem,,,8.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.45,,,percent of total billed charges,,,7.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.49,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,6.84,,,percent of total billed charges,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,3.13,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,,,,,,,8.45,,,percent of total billed charges,,,8.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.68,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,,,,,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,7.86,,,percent of total billed charges,,,6.34,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,,,,,,,5.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.98,,,percent of total billed charges,,
SOTALOL HCL 80 MG TAB,2500016794,CDM,637,RC,6050500800,NDC,999,EAPG,,,,outpatient,facility,80,UN,8.45,8.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUCRALFATE 1 GM TAB,2500016860,CDM,637,RC,93221001,NDC,,,,,,inpatient,facility,1,UN,2.64,2.64,0.21,2.64,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,
SUCRALFATE 1 GM TAB,2500016860,CDM,637,RC,93221001,NDC,,,,,,outpatient,facility,1,UN,2.64,2.64,0.21,548.68,,1.87,,,percent of total billed charges,,,0.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.64,,,percent of total billed charges,,,1.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.97,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.64,,,fee schedule,,,2.64,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,1.37,,,percent of total billed charges,,,1.45,,,percent of total billed charges,,,,,,,,,1.56,,,percent of total billed charges,,,548.68,,,per diem,,,2.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.64,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,0.98,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,2.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.21,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,1.98,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.56,,,percent of total billed charges,,
SUCRALFATE 1 GM TAB,2500016860,CDM,637,RC,93221001,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.64,2.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUCRALFATE 1 GM/10 ML UDC,2500016861,CDM,637,RC,121074740,NDC,,,,,,inpatient,facility,10,UN,40.19,40.19,3.22,40.19,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,,,,,,,,40.19,,,percent of total billed charges,,,20.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.11,,,percent of total billed charges,,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,,34.16,,,percent of total billed charges,,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,,21.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.68,,,percent of total billed charges,,
SUCRALFATE 1 GM/10 ML UDC,2500016861,CDM,637,RC,121074740,NDC,,,,,,outpatient,facility,10,UN,40.19,40.19,3.22,548.68,,28.5,,,percent of total billed charges,,,9.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,40.19,,,percent of total billed charges,,,25.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,28.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,28.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,14.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,40.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,40.19,,,fee schedule,,,40.19,,,percent of total billed charges,,,,,,,,,40.19,,,percent of total billed charges,,,24.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.64,,,percent of total billed charges,,,,,,,,,,,,,,,21.7,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,,,,,,,23.71,,,percent of total billed charges,,,548.68,,,per diem,,,40.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,40.19,,,percent of total billed charges,,,34.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.34,,,percent of total billed charges,,,40.19,,,percent of total billed charges,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.11,,,percent of total billed charges,,,32.52,,,percent of total billed charges,,,,,,,,,,,,,,,16.08,,,percent of total billed charges,,,,,,,,,14.87,,,percent of total billed charges,,,14.87,,,percent of total billed charges,,,,,,,,,40.19,,,percent of total billed charges,,,40.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.22,,,percent of total billed charges,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,,40.19,,,percent of total billed charges,,,,,,,,,37.38,,,percent of total billed charges,,,,,,,,,,,,,,,37.38,,,percent of total billed charges,,,37.38,,,percent of total billed charges,,,37.38,,,percent of total billed charges,,,30.14,,,percent of total billed charges,,,40.19,,,percent of total billed charges,,,40.19,,,percent of total billed charges,,,40.19,,,percent of total billed charges,,,,,,,,,28.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,23.68,,,percent of total billed charges,,
SUCRALFATE 1 GM/10 ML UDC,2500016861,CDM,637,RC,121074740,NDC,999,EAPG,,,,outpatient,facility,10,UN,40.19,40.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SULFACETAMIDE 10  OPH 15 ML,2500016902,CDM,637,RC,2420867004,NDC,,,,,,inpatient,facility,15,UN,201.3,201.3,16.1,201.3,,,,,,,,,,,,,,201.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.3,,,percent of total billed charges,,,,,,,,,201.3,,,percent of total billed charges,,,102.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.78,,,percent of total billed charges,,,,,,,,,,,,,,,201.3,,,percent of total billed charges,,,171.1,,,percent of total billed charges,,,,,,,,,,,,,,,201.3,,,percent of total billed charges,,,106.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,201.3,,,percent of total billed charges,,,,,,,,,,,,,,,16.1,,,percent of total billed charges,,,201.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,201.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.61,,,percent of total billed charges,,
SULFACETAMIDE 10  OPH 15 ML,2500016902,CDM,637,RC,2420867004,NDC,,,,,,outpatient,facility,15,UN,201.3,201.3,16.1,548.68,,142.74,,,percent of total billed charges,,,49.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,201.3,,,percent of total billed charges,,,126.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,141.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,141.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,201.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,73.68,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,201.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,201.3,,,fee schedule,,,201.3,,,percent of total billed charges,,,,,,,,,201.3,,,percent of total billed charges,,,123.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.43,,,percent of total billed charges,,,,,,,,,,,,,,,108.7,,,percent of total billed charges,,,104.68,,,percent of total billed charges,,,110.72,,,percent of total billed charges,,,,,,,,,118.77,,,percent of total billed charges,,,548.68,,,per diem,,,201.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,201.3,,,percent of total billed charges,,,171.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.91,,,percent of total billed charges,,,201.3,,,percent of total billed charges,,,201.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.8,,,percent of total billed charges,,,162.89,,,percent of total billed charges,,,,,,,,,,,,,,,80.52,,,percent of total billed charges,,,,,,,,,74.48,,,percent of total billed charges,,,74.48,,,percent of total billed charges,,,,,,,,,201.3,,,percent of total billed charges,,,201.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,201.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.1,,,percent of total billed charges,,,201.3,,,percent of total billed charges,,,,,,,,,,,,,,,201.3,,,percent of total billed charges,,,201.3,,,percent of total billed charges,,,,,,,,,187.25,,,percent of total billed charges,,,,,,,,,,,,,,,187.25,,,percent of total billed charges,,,187.25,,,percent of total billed charges,,,187.25,,,percent of total billed charges,,,150.98,,,percent of total billed charges,,,201.3,,,percent of total billed charges,,,201.3,,,percent of total billed charges,,,201.3,,,percent of total billed charges,,,,,,,,,141.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.65,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,118.61,,,percent of total billed charges,,
SULFACETAMIDE 10  OPH 15 ML,2500016902,CDM,637,RC,2420867004,NDC,999,EAPG,,,,outpatient,facility,15,UN,201.3,201.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SULFASALAZINE 500 MG TAB,2500016950,CDM,637,RC,5976250005,NDC,,,,,,inpatient,facility,500,UN,0.62,0.62,0.05,0.62,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,
SULFASALAZINE 500 MG TAB,2500016950,CDM,637,RC,5976250005,NDC,,,,,,outpatient,facility,500,UN,0.62,0.62,0.05,548.68,,0.44,,,percent of total billed charges,,,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.62,,,percent of total billed charges,,,0.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.62,,,fee schedule,,,0.62,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,0.37,,,percent of total billed charges,,,548.68,,,per diem,,,0.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.62,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,0.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.58,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.37,,,percent of total billed charges,,
SULFASALAZINE 500 MG TAB,2500016950,CDM,637,RC,5976250005,NDC,999,EAPG,,,,outpatient,facility,500,UN,0.62,0.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUMATRIPTAN SUCC 25 MG TAB,2500017010,CDM,637,RC,6586214636,NDC,,,,,,inpatient,facility,25,UN,89.26,89.26,7.14,89.26,,,,,,,,,,,,,,89.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.26,,,percent of total billed charges,,,,,,,,,89.26,,,percent of total billed charges,,,45.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.56,,,percent of total billed charges,,,,,,,,,,,,,,,89.26,,,percent of total billed charges,,,75.87,,,percent of total billed charges,,,,,,,,,,,,,,,89.26,,,percent of total billed charges,,,47.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,89.26,,,percent of total billed charges,,,,,,,,,,,,,,,7.14,,,percent of total billed charges,,,89.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,89.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.59,,,percent of total billed charges,,
SUMATRIPTAN SUCC 25 MG TAB,2500017010,CDM,637,RC,6586214636,NDC,,,,,,outpatient,facility,25,UN,89.26,89.26,7.14,548.68,,63.29,,,percent of total billed charges,,,21.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,89.26,,,percent of total billed charges,,,55.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,62.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,62.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,89.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,32.67,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,89.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,89.26,,,fee schedule,,,89.26,,,percent of total billed charges,,,,,,,,,89.26,,,percent of total billed charges,,,54.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.6,,,percent of total billed charges,,,,,,,,,,,,,,,48.2,,,percent of total billed charges,,,46.42,,,percent of total billed charges,,,49.09,,,percent of total billed charges,,,,,,,,,52.66,,,percent of total billed charges,,,548.68,,,per diem,,,89.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,89.26,,,percent of total billed charges,,,75.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.41,,,percent of total billed charges,,,89.26,,,percent of total billed charges,,,89.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.21,,,percent of total billed charges,,,72.23,,,percent of total billed charges,,,,,,,,,,,,,,,35.7,,,percent of total billed charges,,,,,,,,,33.03,,,percent of total billed charges,,,33.03,,,percent of total billed charges,,,,,,,,,89.26,,,percent of total billed charges,,,89.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,89.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.14,,,percent of total billed charges,,,89.26,,,percent of total billed charges,,,,,,,,,,,,,,,89.26,,,percent of total billed charges,,,89.26,,,percent of total billed charges,,,,,,,,,83.03,,,percent of total billed charges,,,,,,,,,,,,,,,83.03,,,percent of total billed charges,,,83.03,,,percent of total billed charges,,,83.03,,,percent of total billed charges,,,66.95,,,percent of total billed charges,,,89.26,,,percent of total billed charges,,,89.26,,,percent of total billed charges,,,89.26,,,percent of total billed charges,,,,,,,,,62.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.63,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,52.59,,,percent of total billed charges,,
SUMATRIPTAN SUCC 25 MG TAB,2500017010,CDM,637,RC,6586214636,NDC,999,EAPG,,,,outpatient,facility,25,UN,89.26,89.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TACROLIMUS 1 MG CAP,2500017060,CDM,636,RC,J7507,HCPCS,6808445001,NDC,,,,inpatient,facility,1,UN,14.72,14.72,1.18,14.72,,,,,,,,,,,,,,14.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.72,,,percent of total billed charges,,,,,,,,,14.72,,,percent of total billed charges,,,7.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.83,,,percent of total billed charges,,,,,,,,,,,,,,,14.72,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,14.72,,,percent of total billed charges,,,7.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.72,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,14.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.67,,,percent of total billed charges,,
TACROLIMUS 1 MG CAP,2500017060,CDM,636,RC,J7507,HCPCS,6808445001,NDC,,,,outpatient,facility,1,UN,14.72,14.72,0.24,548.68,,10.44,,,percent of total billed charges,,,3.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.72,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,14.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.39,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.72,,,fee schedule,,,14.72,,,percent of total billed charges,,,,,,,,,14.72,,,percent of total billed charges,,,9.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,8.68,,,percent of total billed charges,,,548.68,,,per diem,,,14.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.72,,,percent of total billed charges,,,12.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.82,,,percent of total billed charges,,,14.72,,,percent of total billed charges,,,14.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,11.91,,,percent of total billed charges,,,,,,,,,,,,,,,5.89,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,14.72,,,percent of total billed charges,,,14.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.18,,,percent of total billed charges,,,14.72,,,percent of total billed charges,,,,,,,,,,,,,,,14.72,,,percent of total billed charges,,,14.72,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.24,,,fee schedule,,,14.72,,,percent of total billed charges,,,14.72,,,percent of total billed charges,,,14.72,,,percent of total billed charges,,,,,,,,,10.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.67,,,percent of total billed charges,,
TACROLIMUS 1 MG CAP,2500017060,CDM,636,RC,J7507,HCPCS,6808445001,NDC,496,EAPG,,outpatient,facility,1,UN,14.72,14.72,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TACROLIMUS 0.5 MG CAP,2500017061,CDM,637,RC,J7507,HCPCS,904662361,NDC,,,,inpatient,facility,0.5,UN,3.47,3.47,0.28,3.47,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,,,,,,,3.47,,,percent of total billed charges,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,
TACROLIMUS 0.5 MG CAP,2500017061,CDM,637,RC,J7507,HCPCS,904662361,NDC,,,,outpatient,facility,0.5,UN,3.47,3.47,0.24,548.68,,2.46,,,percent of total billed charges,,,0.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.47,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.27,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.47,,,fee schedule,,,3.47,,,percent of total billed charges,,,,,,,,,3.47,,,percent of total billed charges,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,2.05,,,percent of total billed charges,,,548.68,,,per diem,,,3.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.47,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3.47,,,percent of total billed charges,,,3.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.24,,,fee schedule,,,3.47,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,,,,,,,2.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.04,,,percent of total billed charges,,
TACROLIMUS 0.5 MG CAP,2500017061,CDM,637,RC,J7507,HCPCS,904662361,NDC,496,EAPG,,outpatient,facility,0.5,UN,3.47,3.47,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TALC 4 GM POWD,2500017073,CDM,250,RC,6232744444,NDC,,,,,,inpatient,facility,4,UN,55.44,55.44,4.44,55.44,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,55.44,,,percent of total billed charges,,,28.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.26,,,percent of total billed charges,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,47.12,,,percent of total billed charges,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,29.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,4.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.67,,,percent of total billed charges,,
TALC 4 GM POWD,2500017073,CDM,250,RC,6232744444,NDC,,,,,,outpatient,facility,4,UN,55.44,55.44,4.44,548.68,,39.31,,,percent of total billed charges,,,13.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,55.44,,,percent of total billed charges,,,34.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,38.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,38.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,20.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,55.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,55.44,,,fee schedule,,,55.44,,,percent of total billed charges,,,,,,,,,55.44,,,percent of total billed charges,,,33.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,32.71,,,percent of total billed charges,,,548.68,,,per diem,,,55.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,55.44,,,percent of total billed charges,,,47.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.4,,,percent of total billed charges,,,44.86,,,percent of total billed charges,,,,,,,,,,,,,,,22.18,,,percent of total billed charges,,,,,,,,,22.18,,,percent of total billed charges,,,22.18,,,percent of total billed charges,,,,,,,,,55.44,,,percent of total billed charges,,,55.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,55.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,,,,,,,55.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,22.18,,,percent of total billed charges,,,,,,,,,,,,,,,22.18,,,percent of total billed charges,,,22.18,,,percent of total billed charges,,,22.18,,,percent of total billed charges,,,41.58,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,55.44,,,percent of total billed charges,,,,,,,,,38.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,32.67,,,percent of total billed charges,,
TALC 4 GM POWD,2500017073,CDM,250,RC,6232744444,NDC,999,EAPG,,,,outpatient,facility,4,UN,55.44,55.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TAMOXIFEN 10 MG TAB,2500017080,CDM,637,RC,378014491,NDC,,,,,,inpatient,facility,10,UN,6.23,6.23,0.5,6.23,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,6.23,,,percent of total billed charges,,,3.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.74,,,percent of total billed charges,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,5.3,,,percent of total billed charges,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.67,,,percent of total billed charges,,
TAMOXIFEN 10 MG TAB,2500017080,CDM,637,RC,378014491,NDC,,,,,,outpatient,facility,10,UN,6.23,6.23,0.5,548.68,,4.42,,,percent of total billed charges,,,1.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.23,,,percent of total billed charges,,,3.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.28,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.23,,,fee schedule,,,6.23,,,percent of total billed charges,,,,,,,,,6.23,,,percent of total billed charges,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.44,,,percent of total billed charges,,,,,,,,,,,,,,,3.36,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,,,,,,,3.68,,,percent of total billed charges,,,548.68,,,per diem,,,6.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.23,,,percent of total billed charges,,,5.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.2,,,percent of total billed charges,,,5.04,,,percent of total billed charges,,,,,,,,,,,,,,,2.49,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,6.23,,,percent of total billed charges,,,6.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.5,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,,,,,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,5.8,,,percent of total billed charges,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,4.67,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,6.23,,,percent of total billed charges,,,,,,,,,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.67,,,percent of total billed charges,,
TAMOXIFEN 10 MG TAB,2500017080,CDM,637,RC,378014491,NDC,999,EAPG,,,,outpatient,facility,10,UN,6.23,6.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TETRAHYDROZOLINE 0.05  OP 15ML,2500017210,CDM,637,RC,5295959701,NDC,,,,,,inpatient,facility,15,UN,20.79,20.79,1.66,20.79,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,,,,,,,20.79,,,percent of total billed charges,,,10.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,17.67,,,percent of total billed charges,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,11.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.25,,,percent of total billed charges,,
TETRAHYDROZOLINE 0.05  OP 15ML,2500017210,CDM,637,RC,5295959701,NDC,,,,,,outpatient,facility,15,UN,20.79,20.79,1.66,548.68,,14.74,,,percent of total billed charges,,,5.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,20.79,,,percent of total billed charges,,,13.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,14.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,14.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,20.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,20.79,,,fee schedule,,,20.79,,,percent of total billed charges,,,,,,,,,20.79,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.81,,,percent of total billed charges,,,,,,,,,,,,,,,11.23,,,percent of total billed charges,,,10.81,,,percent of total billed charges,,,11.43,,,percent of total billed charges,,,,,,,,,12.27,,,percent of total billed charges,,,548.68,,,per diem,,,20.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,20.79,,,percent of total billed charges,,,17.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.04,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.02,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,,,,,,,,,,,,,8.32,,,percent of total billed charges,,,,,,,,,7.69,,,percent of total billed charges,,,7.69,,,percent of total billed charges,,,,,,,,,20.79,,,percent of total billed charges,,,20.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.66,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,,,,,,,19.34,,,percent of total billed charges,,,,,,,,,,,,,,,19.34,,,percent of total billed charges,,,19.34,,,percent of total billed charges,,,19.34,,,percent of total billed charges,,,15.59,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,,,,,,,14.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,12.25,,,percent of total billed charges,,
TETRAHYDROZOLINE 0.05  OP 15ML,2500017210,CDM,637,RC,5295959701,NDC,999,EAPG,,,,outpatient,facility,15,UN,20.79,20.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THEOPHYLLINE 400 MG CR TAB,2500017234,CDM,637,RC,6846238001,NDC,,,,,,inpatient,facility,400,UN,5.51,5.51,0.44,5.51,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,5.51,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.25,,,percent of total billed charges,,
THEOPHYLLINE 400 MG CR TAB,2500017234,CDM,637,RC,6846238001,NDC,,,,,,outpatient,facility,400,UN,5.51,5.51,0.44,548.68,,3.91,,,percent of total billed charges,,,1.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.51,,,percent of total billed charges,,,3.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.02,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.51,,,fee schedule,,,5.51,,,percent of total billed charges,,,,,,,,,5.51,,,percent of total billed charges,,,3.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,3.25,,,percent of total billed charges,,,548.68,,,per diem,,,5.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.51,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.72,,,percent of total billed charges,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,2.2,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,5.51,,,percent of total billed charges,,,5.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.44,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,5.13,,,percent of total billed charges,,,,,,,,,,,,,,,5.13,,,percent of total billed charges,,,5.13,,,percent of total billed charges,,,5.13,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,5.51,,,percent of total billed charges,,,,,,,,,3.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.25,,,percent of total billed charges,,
THEOPHYLLINE 400 MG CR TAB,2500017234,CDM,637,RC,6846238001,NDC,999,EAPG,,,,outpatient,facility,400,UN,5.51,5.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THEOPHYLLINE SR 300 MG TAB,2500017256,CDM,637,RC,6233202531,NDC,,,,,,inpatient,facility,300,UN,14.19,14.19,1.14,14.19,,,,,,,,,,,,,,14.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.19,,,percent of total billed charges,,,,,,,,,14.19,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,14.19,,,percent of total billed charges,,,12.06,,,percent of total billed charges,,,,,,,,,,,,,,,14.19,,,percent of total billed charges,,,7.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.19,,,percent of total billed charges,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,14.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.36,,,percent of total billed charges,,
THEOPHYLLINE SR 300 MG TAB,2500017256,CDM,637,RC,6233202531,NDC,,,,,,outpatient,facility,300,UN,14.19,14.19,1.14,548.68,,10.06,,,percent of total billed charges,,,3.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.19,,,percent of total billed charges,,,8.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.19,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.19,,,fee schedule,,,14.19,,,percent of total billed charges,,,,,,,,,14.19,,,percent of total billed charges,,,8.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.11,,,percent of total billed charges,,,,,,,,,,,,,,,7.66,,,percent of total billed charges,,,7.38,,,percent of total billed charges,,,7.8,,,percent of total billed charges,,,,,,,,,8.37,,,percent of total billed charges,,,548.68,,,per diem,,,14.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.19,,,percent of total billed charges,,,12.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.54,,,percent of total billed charges,,,14.19,,,percent of total billed charges,,,14.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.57,,,percent of total billed charges,,,11.48,,,percent of total billed charges,,,,,,,,,,,,,,,5.68,,,percent of total billed charges,,,,,,,,,5.25,,,percent of total billed charges,,,5.25,,,percent of total billed charges,,,,,,,,,14.19,,,percent of total billed charges,,,14.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.14,,,percent of total billed charges,,,14.19,,,percent of total billed charges,,,,,,,,,,,,,,,14.19,,,percent of total billed charges,,,14.19,,,percent of total billed charges,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,10.64,,,percent of total billed charges,,,14.19,,,percent of total billed charges,,,14.19,,,percent of total billed charges,,,14.19,,,percent of total billed charges,,,,,,,,,9.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.36,,,percent of total billed charges,,
THEOPHYLLINE SR 300 MG TAB,2500017256,CDM,637,RC,6233202531,NDC,999,EAPG,,,,outpatient,facility,300,UN,14.19,14.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THIAMINE HCL 100 MG TAB,2500017273,CDM,637,RC,8068109800,NDC,,,,,,inpatient,facility,100,UN,1.95,1.95,0.16,1.95,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,1.95,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,
THIAMINE HCL 100 MG TAB,2500017273,CDM,637,RC,8068109800,NDC,,,,,,outpatient,facility,100,UN,1.95,1.95,0.16,548.68,,1.38,,,percent of total billed charges,,,0.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.95,,,percent of total billed charges,,,1.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.95,,,fee schedule,,,1.95,,,percent of total billed charges,,,,,,,,,1.95,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,1.15,,,percent of total billed charges,,,548.68,,,per diem,,,1.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.95,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,0.72,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,1.95,,,percent of total billed charges,,,1.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,1.95,,,percent of total billed charges,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.15,,,percent of total billed charges,,
THIAMINE HCL 100 MG TAB,2500017273,CDM,637,RC,8068109800,NDC,999,EAPG,,,,outpatient,facility,100,UN,1.95,1.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THIAMINE HCL 100 MG/ML INJ,2500017274,CDM,636,RC,J3411,HCPCS,6332301302,NDC,,,,inpatient,facility,2,UN,32.83,32.83,2.63,32.83,,,,,,,,,,,,,,32.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.83,,,percent of total billed charges,,,,,,,,,32.83,,,percent of total billed charges,,,16.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.7,,,percent of total billed charges,,,,,,,,,,,,,,,32.83,,,percent of total billed charges,,,27.91,,,percent of total billed charges,,,,,,,,,,,,,,,32.83,,,percent of total billed charges,,,17.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,32.83,,,percent of total billed charges,,,,,,,,,,,,,,,2.63,,,percent of total billed charges,,,32.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.34,,,percent of total billed charges,,
THIAMINE HCL 100 MG/ML INJ,2500017274,CDM,636,RC,J3411,HCPCS,6332301302,NDC,,,,outpatient,facility,2,UN,32.83,32.83,2.01,548.68,,23.28,,,percent of total billed charges,,,8.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,32.83,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,32.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.02,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.58,,,fee schedule,,,32.83,,,fee schedule,,,32.83,,,percent of total billed charges,,,,,,,,,32.83,,,percent of total billed charges,,,20.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,19.37,,,percent of total billed charges,,,548.68,,,per diem,,,32.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,32.83,,,percent of total billed charges,,,27.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.44,,,percent of total billed charges,,,32.83,,,percent of total billed charges,,,32.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.15,,,percent of total billed charges,,,26.57,,,percent of total billed charges,,,,,,,,,,,,,,,13.13,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,32.83,,,percent of total billed charges,,,32.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,32.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.63,,,percent of total billed charges,,,32.83,,,percent of total billed charges,,,,,,,,,,,,,,,32.83,,,percent of total billed charges,,,32.83,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.01,,,fee schedule,,,32.83,,,percent of total billed charges,,,32.83,,,percent of total billed charges,,,32.83,,,percent of total billed charges,,,,,,,,,23.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,19.34,,,percent of total billed charges,,
THIAMINE HCL 100 MG/ML INJ,2500017274,CDM,636,RC,J3411,HCPCS,6332301302,NDC,496,EAPG,,outpatient,facility,2,UN,32.83,32.83,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THIOTHIXENE 5 MG CAP,2500017323,CDM,637,RC,5107958820,NDC,,,,,,inpatient,facility,5,UN,11.95,11.95,0.96,11.95,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,,,,,,,,11.95,,,percent of total billed charges,,,6.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.17,,,percent of total billed charges,,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,,10.16,,,percent of total billed charges,,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,,6.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.04,,,percent of total billed charges,,
THIOTHIXENE 5 MG CAP,2500017323,CDM,637,RC,5107958820,NDC,,,,,,outpatient,facility,5,UN,11.95,11.95,0.96,548.68,,8.47,,,percent of total billed charges,,,2.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,11.95,,,percent of total billed charges,,,7.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.37,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,11.95,,,fee schedule,,,11.95,,,percent of total billed charges,,,,,,,,,11.95,,,percent of total billed charges,,,7.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,6.45,,,percent of total billed charges,,,6.21,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,,,,,,,7.05,,,percent of total billed charges,,,548.68,,,per diem,,,11.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11.95,,,percent of total billed charges,,,10.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.35,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.06,,,percent of total billed charges,,,9.67,,,percent of total billed charges,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,,,,,,,11.95,,,percent of total billed charges,,,11.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.96,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,11.95,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,,,,,,,11.12,,,percent of total billed charges,,,,,,,,,,,,,,,11.12,,,percent of total billed charges,,,11.12,,,percent of total billed charges,,,11.12,,,percent of total billed charges,,,8.96,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,11.95,,,percent of total billed charges,,,,,,,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.04,,,percent of total billed charges,,
THIOTHIXENE 5 MG CAP,2500017323,CDM,637,RC,5107958820,NDC,999,EAPG,,,,outpatient,facility,5,UN,11.95,11.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THROMBIN 5000 U INJ,2500017334,CDM,250,RC,6079321505,NDC,,,,,,inpatient,facility,5000,UN,238.03,238.03,19.04,238.03,,,,,,,,,,,,,,238.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.03,,,percent of total billed charges,,,,,,,,,238.03,,,percent of total billed charges,,,121.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.82,,,percent of total billed charges,,,,,,,,,,,,,,,238.03,,,percent of total billed charges,,,202.33,,,percent of total billed charges,,,,,,,,,,,,,,,238.03,,,percent of total billed charges,,,126.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,238.03,,,percent of total billed charges,,,,,,,,,,,,,,,19.04,,,percent of total billed charges,,,238.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,238.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.25,,,percent of total billed charges,,
THROMBIN 5000 U INJ,2500017334,CDM,250,RC,6079321505,NDC,,,,,,outpatient,facility,5000,UN,238.03,238.03,19.04,548.68,,168.79,,,percent of total billed charges,,,58.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,238.03,,,percent of total billed charges,,,149.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,167.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,167.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,238.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,87.12,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,238.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,238.03,,,fee schedule,,,238.03,,,percent of total billed charges,,,,,,,,,238.03,,,percent of total billed charges,,,145.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,140.44,,,percent of total billed charges,,,548.68,,,per diem,,,238.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,238.03,,,percent of total billed charges,,,202.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.42,,,percent of total billed charges,,,238.03,,,percent of total billed charges,,,238.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.58,,,percent of total billed charges,,,192.61,,,percent of total billed charges,,,,,,,,,,,,,,,95.21,,,percent of total billed charges,,,,,,,,,95.21,,,percent of total billed charges,,,95.21,,,percent of total billed charges,,,,,,,,,238.03,,,percent of total billed charges,,,238.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,238.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.04,,,percent of total billed charges,,,238.03,,,percent of total billed charges,,,,,,,,,,,,,,,238.03,,,percent of total billed charges,,,238.03,,,percent of total billed charges,,,,,,,,,95.21,,,percent of total billed charges,,,,,,,,,,,,,,,95.21,,,percent of total billed charges,,,95.21,,,percent of total billed charges,,,95.21,,,percent of total billed charges,,,178.52,,,percent of total billed charges,,,238.03,,,percent of total billed charges,,,238.03,,,percent of total billed charges,,,238.03,,,percent of total billed charges,,,,,,,,,166.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,140.25,,,percent of total billed charges,,
THROMBIN 5000 U INJ,2500017334,CDM,250,RC,6079321505,NDC,999,EAPG,,,,outpatient,facility,5000,UN,238.03,238.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THROMBIN RECOMBINANT 5000 U,2500017335,CDM,250,RC,338032201,NDC,,,,,,inpatient,facility,5000,UN,283.8,283.8,22.7,283.8,,,,,,,,,,,,,,283.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.8,,,percent of total billed charges,,,,,,,,,283.8,,,percent of total billed charges,,,144.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.28,,,percent of total billed charges,,,,,,,,,,,,,,,283.8,,,percent of total billed charges,,,241.23,,,percent of total billed charges,,,,,,,,,,,,,,,283.8,,,percent of total billed charges,,,150.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,283.8,,,percent of total billed charges,,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,283.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,283.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.21,,,percent of total billed charges,,
THROMBIN RECOMBINANT 5000 U,2500017335,CDM,250,RC,338032201,NDC,,,,,,outpatient,facility,5000,UN,283.8,283.8,22.7,548.68,,201.24,,,percent of total billed charges,,,69.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,283.8,,,percent of total billed charges,,,177.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,199.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,199.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,283.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,103.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,283.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,283.8,,,fee schedule,,,283.8,,,percent of total billed charges,,,,,,,,,283.8,,,percent of total billed charges,,,173.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,167.44,,,percent of total billed charges,,,548.68,,,per diem,,,283.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,283.8,,,percent of total billed charges,,,241.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.73,,,percent of total billed charges,,,283.8,,,percent of total billed charges,,,283.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.45,,,percent of total billed charges,,,229.65,,,percent of total billed charges,,,,,,,,,,,,,,,113.52,,,percent of total billed charges,,,,,,,,,113.52,,,percent of total billed charges,,,113.52,,,percent of total billed charges,,,,,,,,,283.8,,,percent of total billed charges,,,283.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,283.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.7,,,percent of total billed charges,,,283.8,,,percent of total billed charges,,,,,,,,,,,,,,,283.8,,,percent of total billed charges,,,283.8,,,percent of total billed charges,,,,,,,,,113.52,,,percent of total billed charges,,,,,,,,,,,,,,,113.52,,,percent of total billed charges,,,113.52,,,percent of total billed charges,,,113.52,,,percent of total billed charges,,,212.85,,,percent of total billed charges,,,283.8,,,percent of total billed charges,,,283.8,,,percent of total billed charges,,,283.8,,,percent of total billed charges,,,,,,,,,198.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,167.21,,,percent of total billed charges,,
THROMBIN RECOMBINANT 5000 U,2500017335,CDM,250,RC,338032201,NDC,999,EAPG,,,,outpatient,facility,5000,UN,283.8,283.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
THYROID 30 MG TAB,2500017363,CDM,637,RC,456045801,NDC,,,,,,inpatient,facility,30,UN,3.17,3.17,0.25,3.17,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,2.69,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,
THYROID 30 MG TAB,2500017363,CDM,637,RC,456045801,NDC,,,,,,outpatient,facility,30,UN,3.17,3.17,0.25,548.68,,2.25,,,percent of total billed charges,,,0.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.17,,,percent of total billed charges,,,1.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.16,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.17,,,fee schedule,,,3.17,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,1.74,,,percent of total billed charges,,,,,,,,,1.87,,,percent of total billed charges,,,548.68,,,per diem,,,3.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.17,,,percent of total billed charges,,,2.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,1.17,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,3.17,,,percent of total billed charges,,,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.25,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,2.95,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,3.17,,,percent of total billed charges,,,,,,,,,2.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.87,,,percent of total billed charges,,
THYROID 30 MG TAB,2500017363,CDM,637,RC,456045801,NDC,999,EAPG,,,,outpatient,facility,30,UN,3.17,3.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIMOLOL 0.25  OP SOLN 5 ML,2500017401,CDM,637,RC,6131422605,NDC,,,,,,inpatient,facility,5,UN,49.5,49.5,3.96,49.5,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,25.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,42.08,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,26.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.17,,,percent of total billed charges,,
TIMOLOL 0.25  OP SOLN 5 ML,2500017401,CDM,637,RC,6131422605,NDC,,,,,,outpatient,facility,5,UN,49.5,49.5,3.96,548.68,,35.1,,,percent of total billed charges,,,12.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,49.5,,,percent of total billed charges,,,31.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,34.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,34.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,18.12,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,49.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,49.5,,,fee schedule,,,49.5,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,30.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.27,,,percent of total billed charges,,,,,,,,,,,,,,,26.73,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,27.23,,,percent of total billed charges,,,,,,,,,29.2,,,percent of total billed charges,,,548.68,,,per diem,,,49.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,49.5,,,percent of total billed charges,,,42.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.29,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.39,,,percent of total billed charges,,,40.06,,,percent of total billed charges,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,18.32,,,percent of total billed charges,,,18.32,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,49.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,49.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.96,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,46.04,,,percent of total billed charges,,,,,,,,,,,,,,,46.04,,,percent of total billed charges,,,46.04,,,percent of total billed charges,,,46.04,,,percent of total billed charges,,,37.13,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,34.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,29.17,,,percent of total billed charges,,
TIMOLOL 0.25  OP SOLN 5 ML,2500017401,CDM,637,RC,6131422605,NDC,999,EAPG,,,,outpatient,facility,5,UN,49.5,49.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIMOLOL 0.5  OP SOLN 5 ML,2500017404,CDM,637,RC,6131422705,NDC,,,,,,inpatient,facility,5,UN,56.1,56.1,4.49,56.1,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,,,,,,,56.1,,,percent of total billed charges,,,28.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.66,,,percent of total billed charges,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,47.68,,,percent of total billed charges,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,29.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,4.49,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.05,,,percent of total billed charges,,
TIMOLOL 0.5  OP SOLN 5 ML,2500017404,CDM,637,RC,6131422705,NDC,,,,,,outpatient,facility,5,UN,56.1,56.1,4.49,548.68,,39.78,,,percent of total billed charges,,,13.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,56.1,,,percent of total billed charges,,,35.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,39.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,39.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,20.53,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,56.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,56.1,,,fee schedule,,,56.1,,,percent of total billed charges,,,,,,,,,56.1,,,percent of total billed charges,,,34.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.97,,,percent of total billed charges,,,,,,,,,,,,,,,30.29,,,percent of total billed charges,,,29.17,,,percent of total billed charges,,,30.86,,,percent of total billed charges,,,,,,,,,33.1,,,percent of total billed charges,,,548.68,,,per diem,,,56.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,56.1,,,percent of total billed charges,,,47.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.79,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.85,,,percent of total billed charges,,,45.4,,,percent of total billed charges,,,,,,,,,,,,,,,22.44,,,percent of total billed charges,,,,,,,,,20.76,,,percent of total billed charges,,,20.76,,,percent of total billed charges,,,,,,,,,56.1,,,percent of total billed charges,,,56.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,56.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.49,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,56.1,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,,,,,,,52.18,,,percent of total billed charges,,,,,,,,,,,,,,,52.18,,,percent of total billed charges,,,52.18,,,percent of total billed charges,,,52.18,,,percent of total billed charges,,,42.08,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,,,,,,,39.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,33.05,,,percent of total billed charges,,
TIMOLOL 0.5  OP SOLN 5 ML,2500017404,CDM,637,RC,6131422705,NDC,999,EAPG,,,,outpatient,facility,5,UN,56.1,56.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIZANIDINE HCL 4 MG TAB,2500017420,CDM,637,RC,904641861,NDC,,,,,,inpatient,facility,4,UN,1.75,1.75,0.14,1.75,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,
TIZANIDINE HCL 4 MG TAB,2500017420,CDM,637,RC,904641861,NDC,,,,,,outpatient,facility,4,UN,1.75,1.75,0.14,548.68,,1.24,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.75,,,percent of total billed charges,,,1.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.64,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.75,,,fee schedule,,,1.75,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,1.03,,,percent of total billed charges,,,548.68,,,per diem,,,1.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.75,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,,,,0.65,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.14,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.03,,,percent of total billed charges,,
TIZANIDINE HCL 4 MG TAB,2500017420,CDM,637,RC,904641861,NDC,999,EAPG,,,,outpatient,facility,4,UN,1.75,1.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TOBRAMYCIN 0.3  OP OINT 3.5 GM,2500017440,CDM,637,RC,65064435,NDC,,,,,,inpatient,facility,3.5,UN,707.39,707.39,56.59,707.39,,,,,,,,,,,,,,707.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,707.39,,,percent of total billed charges,,,,,,,,,707.39,,,percent of total billed charges,,,361.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,602.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,424.43,,,percent of total billed charges,,,,,,,,,,,,,,,707.39,,,percent of total billed charges,,,601.28,,,percent of total billed charges,,,,,,,,,,,,,,,707.39,,,percent of total billed charges,,,375.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,707.39,,,percent of total billed charges,,,,,,,,,,,,,,,56.59,,,percent of total billed charges,,,707.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,707.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,416.79,,,percent of total billed charges,,
TOBRAMYCIN 0.3  OP OINT 3.5 GM,2500017440,CDM,637,RC,65064435,NDC,,,,,,outpatient,facility,3.5,UN,707.39,707.39,56.59,707.39,,501.61,,,percent of total billed charges,,,172.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,707.39,,,percent of total billed charges,,,443.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,497.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,497.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,707.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,258.9,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,707.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,707.39,,,fee schedule,,,707.39,,,percent of total billed charges,,,,,,,,,707.39,,,percent of total billed charges,,,433.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,504.02,,,percent of total billed charges,,,,,,,,,,,,,,,381.99,,,percent of total billed charges,,,367.84,,,percent of total billed charges,,,389.06,,,percent of total billed charges,,,,,,,,,417.36,,,percent of total billed charges,,,548.68,,,per diem,,,707.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,707.39,,,percent of total billed charges,,,601.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,375.69,,,percent of total billed charges,,,707.39,,,percent of total billed charges,,,707.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,477.21,,,percent of total billed charges,,,572.42,,,percent of total billed charges,,,,,,,,,,,,,,,282.96,,,percent of total billed charges,,,,,,,,,261.73,,,percent of total billed charges,,,261.73,,,percent of total billed charges,,,,,,,,,707.39,,,percent of total billed charges,,,707.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,707.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,56.59,,,percent of total billed charges,,,707.39,,,percent of total billed charges,,,,,,,,,,,,,,,707.39,,,percent of total billed charges,,,707.39,,,percent of total billed charges,,,,,,,,,658.01,,,percent of total billed charges,,,,,,,,,,,,,,,658.01,,,percent of total billed charges,,,658.01,,,percent of total billed charges,,,658.01,,,percent of total billed charges,,,530.54,,,percent of total billed charges,,,707.39,,,percent of total billed charges,,,707.39,,,percent of total billed charges,,,707.39,,,percent of total billed charges,,,,,,,,,495.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,353.69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,416.79,,,percent of total billed charges,,
TOBRAMYCIN 0.3  OP OINT 3.5 GM,2500017440,CDM,637,RC,65064435,NDC,999,EAPG,,,,outpatient,facility,3.5,UN,707.39,707.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TOBRAMYCIN 0.3  OP SOLN 5 ML,2500017441,CDM,637,RC,6233251805,NDC,,,,,,inpatient,facility,5,UN,112.13,112.13,8.97,112.13,,,,,,,,,,,,,,112.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.13,,,percent of total billed charges,,,,,,,,,112.13,,,percent of total billed charges,,,57.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.28,,,percent of total billed charges,,,,,,,,,,,,,,,112.13,,,percent of total billed charges,,,95.31,,,percent of total billed charges,,,,,,,,,,,,,,,112.13,,,percent of total billed charges,,,59.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,112.13,,,percent of total billed charges,,,,,,,,,,,,,,,8.97,,,percent of total billed charges,,,112.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.07,,,percent of total billed charges,,
TOBRAMYCIN 0.3  OP SOLN 5 ML,2500017441,CDM,637,RC,6233251805,NDC,,,,,,outpatient,facility,5,UN,112.13,112.13,8.97,548.68,,79.51,,,percent of total billed charges,,,27.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,112.13,,,percent of total billed charges,,,70.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,78.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,78.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,112.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,41.04,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,112.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,112.13,,,fee schedule,,,112.13,,,percent of total billed charges,,,,,,,,,112.13,,,percent of total billed charges,,,68.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.89,,,percent of total billed charges,,,,,,,,,,,,,,,60.55,,,percent of total billed charges,,,58.31,,,percent of total billed charges,,,61.67,,,percent of total billed charges,,,,,,,,,66.16,,,percent of total billed charges,,,548.68,,,per diem,,,112.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,112.13,,,percent of total billed charges,,,95.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.55,,,percent of total billed charges,,,112.13,,,percent of total billed charges,,,112.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.64,,,percent of total billed charges,,,90.74,,,percent of total billed charges,,,,,,,,,,,,,,,44.85,,,percent of total billed charges,,,,,,,,,41.49,,,percent of total billed charges,,,41.49,,,percent of total billed charges,,,,,,,,,112.13,,,percent of total billed charges,,,112.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,112.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.97,,,percent of total billed charges,,,112.13,,,percent of total billed charges,,,,,,,,,,,,,,,112.13,,,percent of total billed charges,,,112.13,,,percent of total billed charges,,,,,,,,,104.3,,,percent of total billed charges,,,,,,,,,,,,,,,104.3,,,percent of total billed charges,,,104.3,,,percent of total billed charges,,,104.3,,,percent of total billed charges,,,84.1,,,percent of total billed charges,,,112.13,,,percent of total billed charges,,,112.13,,,percent of total billed charges,,,112.13,,,percent of total billed charges,,,,,,,,,78.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,66.07,,,percent of total billed charges,,
TOBRAMYCIN 0.3  OP SOLN 5 ML,2500017441,CDM,637,RC,6233251805,NDC,999,EAPG,,,,outpatient,facility,5,UN,112.13,112.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TOBRAMYCIN/DEXA OP OINT 3.5 GM,2500017450,CDM,637,RC,78087601,NDC,,,,,,inpatient,facility,3.5,UN,895.09,895.09,71.61,895.09,,,,,,,,,,,,,,895.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,895.09,,,percent of total billed charges,,,,,,,,,895.09,,,percent of total billed charges,,,457.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,762.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.05,,,percent of total billed charges,,,,,,,,,,,,,,,895.09,,,percent of total billed charges,,,760.83,,,percent of total billed charges,,,,,,,,,,,,,,,895.09,,,percent of total billed charges,,,475.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,895.09,,,percent of total billed charges,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,895.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,895.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,527.39,,,percent of total billed charges,,
TOBRAMYCIN/DEXA OP OINT 3.5 GM,2500017450,CDM,637,RC,78087601,NDC,,,,,,outpatient,facility,3.5,UN,895.09,895.09,71.61,895.09,,634.71,,,percent of total billed charges,,,218.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,895.09,,,percent of total billed charges,,,560.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,629.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,629.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,895.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,327.6,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,895.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,895.09,,,fee schedule,,,895.09,,,percent of total billed charges,,,,,,,,,895.09,,,percent of total billed charges,,,548.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,637.75,,,percent of total billed charges,,,,,,,,,,,,,,,483.35,,,percent of total billed charges,,,465.45,,,percent of total billed charges,,,492.3,,,percent of total billed charges,,,,,,,,,528.1,,,percent of total billed charges,,,548.68,,,per diem,,,895.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,895.09,,,percent of total billed charges,,,760.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,475.38,,,percent of total billed charges,,,895.09,,,percent of total billed charges,,,895.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,603.83,,,percent of total billed charges,,,724.31,,,percent of total billed charges,,,,,,,,,,,,,,,358.04,,,percent of total billed charges,,,,,,,,,331.18,,,percent of total billed charges,,,331.18,,,percent of total billed charges,,,,,,,,,895.09,,,percent of total billed charges,,,895.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,895.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,71.61,,,percent of total billed charges,,,895.09,,,percent of total billed charges,,,,,,,,,,,,,,,895.09,,,percent of total billed charges,,,895.09,,,percent of total billed charges,,,,,,,,,832.61,,,percent of total billed charges,,,,,,,,,,,,,,,832.61,,,percent of total billed charges,,,832.61,,,percent of total billed charges,,,832.61,,,percent of total billed charges,,,671.32,,,percent of total billed charges,,,895.09,,,percent of total billed charges,,,895.09,,,percent of total billed charges,,,895.09,,,percent of total billed charges,,,,,,,,,627.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,527.39,,,percent of total billed charges,,
TOBRAMYCIN/DEXA OP OINT 3.5 GM,2500017450,CDM,637,RC,78087601,NDC,999,EAPG,,,,outpatient,facility,3.5,UN,895.09,895.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TOBRAMYCIN/DEXA OP SUSP 2.5 ML,2500017452,CDM,637,RC,2420829525,NDC,,,,,,inpatient,facility,2.5,UN,215.36,215.36,17.23,215.36,,,,,,,,,,,,,,215.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.36,,,percent of total billed charges,,,,,,,,,215.36,,,percent of total billed charges,,,109.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.22,,,percent of total billed charges,,,,,,,,,,,,,,,215.36,,,percent of total billed charges,,,183.06,,,percent of total billed charges,,,,,,,,,,,,,,,215.36,,,percent of total billed charges,,,114.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,215.36,,,percent of total billed charges,,,,,,,,,,,,,,,17.23,,,percent of total billed charges,,,215.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,215.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.89,,,percent of total billed charges,,
TOBRAMYCIN/DEXA OP SUSP 2.5 ML,2500017452,CDM,637,RC,2420829525,NDC,,,,,,outpatient,facility,2.5,UN,215.36,215.36,17.23,548.68,,152.71,,,percent of total billed charges,,,52.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,215.36,,,percent of total billed charges,,,134.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,151.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,151.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,215.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,78.82,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,215.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,215.36,,,fee schedule,,,215.36,,,percent of total billed charges,,,,,,,,,215.36,,,percent of total billed charges,,,131.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.44,,,percent of total billed charges,,,,,,,,,,,,,,,116.29,,,percent of total billed charges,,,111.99,,,percent of total billed charges,,,118.45,,,percent of total billed charges,,,,,,,,,127.06,,,percent of total billed charges,,,548.68,,,per diem,,,215.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,215.36,,,percent of total billed charges,,,183.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.38,,,percent of total billed charges,,,215.36,,,percent of total billed charges,,,215.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.28,,,percent of total billed charges,,,174.27,,,percent of total billed charges,,,,,,,,,,,,,,,86.14,,,percent of total billed charges,,,,,,,,,79.68,,,percent of total billed charges,,,79.68,,,percent of total billed charges,,,,,,,,,215.36,,,percent of total billed charges,,,215.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,215.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.23,,,percent of total billed charges,,,215.36,,,percent of total billed charges,,,,,,,,,,,,,,,215.36,,,percent of total billed charges,,,215.36,,,percent of total billed charges,,,,,,,,,200.33,,,percent of total billed charges,,,,,,,,,,,,,,,200.33,,,percent of total billed charges,,,200.33,,,percent of total billed charges,,,200.33,,,percent of total billed charges,,,161.52,,,percent of total billed charges,,,215.36,,,percent of total billed charges,,,215.36,,,percent of total billed charges,,,215.36,,,percent of total billed charges,,,,,,,,,150.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,126.89,,,percent of total billed charges,,
TOBRAMYCIN/DEXA OP SUSP 2.5 ML,2500017452,CDM,637,RC,2420829525,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,215.36,215.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TOPIRAMATE 100 MG TAB,2500017530,CDM,637,RC,6808434401,NDC,,,,,,inpatient,facility,100,UN,20.46,20.46,1.64,20.46,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,,,,,,,20.46,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,17.39,,,percent of total billed charges,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,10.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.06,,,percent of total billed charges,,
TOPIRAMATE 100 MG TAB,2500017530,CDM,637,RC,6808434401,NDC,,,,,,outpatient,facility,100,UN,20.46,20.46,1.64,548.68,,14.51,,,percent of total billed charges,,,4.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,20.46,,,percent of total billed charges,,,12.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,14.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,14.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,20.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,20.46,,,fee schedule,,,20.46,,,percent of total billed charges,,,,,,,,,20.46,,,percent of total billed charges,,,12.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.58,,,percent of total billed charges,,,,,,,,,,,,,,,11.05,,,percent of total billed charges,,,10.64,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,,,,,,,12.07,,,percent of total billed charges,,,548.68,,,per diem,,,20.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,20.46,,,percent of total billed charges,,,17.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.87,,,percent of total billed charges,,,20.46,,,percent of total billed charges,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.8,,,percent of total billed charges,,,16.56,,,percent of total billed charges,,,,,,,,,,,,,,,8.18,,,percent of total billed charges,,,,,,,,,7.57,,,percent of total billed charges,,,7.57,,,percent of total billed charges,,,,,,,,,20.46,,,percent of total billed charges,,,20.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.64,,,percent of total billed charges,,,20.46,,,percent of total billed charges,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,20.46,,,percent of total billed charges,,,,,,,,,19.03,,,percent of total billed charges,,,,,,,,,,,,,,,19.03,,,percent of total billed charges,,,19.03,,,percent of total billed charges,,,19.03,,,percent of total billed charges,,,15.35,,,percent of total billed charges,,,20.46,,,percent of total billed charges,,,20.46,,,percent of total billed charges,,,20.46,,,percent of total billed charges,,,,,,,,,14.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,12.06,,,percent of total billed charges,,
TOPIRAMATE 100 MG TAB,2500017530,CDM,637,RC,6808434401,NDC,999,EAPG,,,,outpatient,facility,100,UN,20.46,20.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TOPIRAMATE 25 MG TAB,2500017533,CDM,637,RC,6808434201,NDC,,,,,,inpatient,facility,25,UN,6.93,6.93,0.55,6.93,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,,,,,,,6.93,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,,percent of total billed charges,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,5.89,,,percent of total billed charges,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,3.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.08,,,percent of total billed charges,,
TOPIRAMATE 25 MG TAB,2500017533,CDM,637,RC,6808434201,NDC,,,,,,outpatient,facility,25,UN,6.93,6.93,0.55,548.68,,4.91,,,percent of total billed charges,,,1.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.93,,,percent of total billed charges,,,4.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.54,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.93,,,fee schedule,,,6.93,,,percent of total billed charges,,,,,,,,,6.93,,,percent of total billed charges,,,4.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,3.74,,,percent of total billed charges,,,3.6,,,percent of total billed charges,,,3.81,,,percent of total billed charges,,,,,,,,,4.09,,,percent of total billed charges,,,548.68,,,per diem,,,6.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.93,,,percent of total billed charges,,,5.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.68,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.67,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,2.56,,,percent of total billed charges,,,2.56,,,percent of total billed charges,,,,,,,,,6.93,,,percent of total billed charges,,,6.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.55,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,6.45,,,percent of total billed charges,,,,,,,,,,,,,,,6.45,,,percent of total billed charges,,,6.45,,,percent of total billed charges,,,6.45,,,percent of total billed charges,,,5.2,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,4.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.08,,,percent of total billed charges,,
TOPIRAMATE 25 MG TAB,2500017533,CDM,637,RC,6808434201,NDC,999,EAPG,,,,outpatient,facility,25,UN,6.93,6.93,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TORSEMIDE 10 MG TAB,2500017540,CDM,637,RC,3172253001,NDC,,,,,,inpatient,facility,10,UN,2.31,2.31,0.18,2.31,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,
TORSEMIDE 10 MG TAB,2500017540,CDM,637,RC,3172253001,NDC,,,,,,outpatient,facility,10,UN,2.31,2.31,0.18,548.68,,1.64,,,percent of total billed charges,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.31,,,percent of total billed charges,,,1.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.85,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.31,,,fee schedule,,,2.31,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,,,,,,,1.36,,,percent of total billed charges,,,548.68,,,per diem,,,2.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.31,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,0.85,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,2.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.36,,,percent of total billed charges,,
TORSEMIDE 10 MG TAB,2500017540,CDM,637,RC,3172253001,NDC,999,EAPG,,,,outpatient,facility,10,UN,2.31,2.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TORSEMIDE 20 MG TAB,2500017541,CDM,637,RC,5026875615,NDC,,,,,,inpatient,facility,20,UN,2.74,2.74,0.22,2.74,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,2.74,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,
TORSEMIDE 20 MG TAB,2500017541,CDM,637,RC,5026875615,NDC,,,,,,outpatient,facility,20,UN,2.74,2.74,0.22,548.68,,1.94,,,percent of total billed charges,,,0.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.74,,,percent of total billed charges,,,1.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.74,,,fee schedule,,,2.74,,,percent of total billed charges,,,,,,,,,2.74,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,1.62,,,percent of total billed charges,,,548.68,,,per diem,,,2.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.74,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.46,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,2.22,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,1.01,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,2.74,,,percent of total billed charges,,,2.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.22,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.55,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,2.74,,,percent of total billed charges,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.61,,,percent of total billed charges,,
TORSEMIDE 20 MG TAB,2500017541,CDM,637,RC,5026875615,NDC,999,EAPG,,,,outpatient,facility,20,UN,2.74,2.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TPN/PPN ADULT,2500017564,CDM,250,RC,338113703,NDC,,,,,,inpatient,facility,3000,UN,198,198,15.84,198,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,198,,,percent of total billed charges,,,101.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,168.3,,,percent of total billed charges,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,105.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,15.84,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.66,,,percent of total billed charges,,
TPN/PPN ADULT,2500017564,CDM,250,RC,338113703,NDC,,,,,,outpatient,facility,3000,UN,198,198,15.84,548.68,,140.4,,,percent of total billed charges,,,48.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,198,,,percent of total billed charges,,,124.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,139.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,139.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,72.47,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,198,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,198,,,fee schedule,,,198,,,percent of total billed charges,,,,,,,,,198,,,percent of total billed charges,,,121.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,116.82,,,percent of total billed charges,,,548.68,,,per diem,,,198,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,198,,,percent of total billed charges,,,168.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,105.16,,,percent of total billed charges,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.57,,,percent of total billed charges,,,160.22,,,percent of total billed charges,,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,,,,,,,79.2,,,percent of total billed charges,,,79.2,,,percent of total billed charges,,,,,,,,,198,,,percent of total billed charges,,,198,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,198,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.84,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,79.2,,,percent of total billed charges,,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,79.2,,,percent of total billed charges,,,79.2,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,198,,,percent of total billed charges,,,,,,,,,138.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,116.66,,,percent of total billed charges,,
TPN/PPN ADULT,2500017564,CDM,250,RC,338113703,NDC,999,EAPG,,,,outpatient,facility,3000,UN,198,198,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRACE ELEMENTS 1 ML INJ,2500017570,CDM,250,RC,517930525,NDC,,,,,,inpatient,facility,1,UN,85.21,85.21,6.82,85.21,,,,,,,,,,,,,,85.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.21,,,percent of total billed charges,,,,,,,,,85.21,,,percent of total billed charges,,,43.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.13,,,percent of total billed charges,,,,,,,,,,,,,,,85.21,,,percent of total billed charges,,,72.43,,,percent of total billed charges,,,,,,,,,,,,,,,85.21,,,percent of total billed charges,,,45.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,85.21,,,percent of total billed charges,,,,,,,,,,,,,,,6.82,,,percent of total billed charges,,,85.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.21,,,percent of total billed charges,,
TRACE ELEMENTS 1 ML INJ,2500017570,CDM,250,RC,517930525,NDC,,,,,,outpatient,facility,1,UN,85.21,85.21,6.82,548.68,,60.42,,,percent of total billed charges,,,20.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,85.21,,,percent of total billed charges,,,53.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,59.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,59.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,85.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,31.19,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,85.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,85.21,,,fee schedule,,,85.21,,,percent of total billed charges,,,,,,,,,85.21,,,percent of total billed charges,,,52.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,50.27,,,percent of total billed charges,,,548.68,,,per diem,,,85.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,85.21,,,percent of total billed charges,,,72.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,45.26,,,percent of total billed charges,,,85.21,,,percent of total billed charges,,,85.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.48,,,percent of total billed charges,,,68.95,,,percent of total billed charges,,,,,,,,,,,,,,,34.08,,,percent of total billed charges,,,,,,,,,34.08,,,percent of total billed charges,,,34.08,,,percent of total billed charges,,,,,,,,,85.21,,,percent of total billed charges,,,85.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,85.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.82,,,percent of total billed charges,,,85.21,,,percent of total billed charges,,,,,,,,,,,,,,,85.21,,,percent of total billed charges,,,85.21,,,percent of total billed charges,,,,,,,,,34.08,,,percent of total billed charges,,,,,,,,,,,,,,,34.08,,,percent of total billed charges,,,34.08,,,percent of total billed charges,,,34.08,,,percent of total billed charges,,,63.91,,,percent of total billed charges,,,85.21,,,percent of total billed charges,,,85.21,,,percent of total billed charges,,,85.21,,,percent of total billed charges,,,,,,,,,59.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,50.21,,,percent of total billed charges,,
TRACE ELEMENTS 1 ML INJ,2500017570,CDM,250,RC,517930525,NDC,999,EAPG,,,,outpatient,facility,1,UN,85.21,85.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAMADOL 50 MG TAB,2500017580,CDM,637,RC,904717961,NDC,,,,,,inpatient,facility,50,UN,0.49,0.49,0.04,0.49,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,
TRAMADOL 50 MG TAB,2500017580,CDM,637,RC,904717961,NDC,,,,,,outpatient,facility,50,UN,0.49,0.49,0.04,548.68,,0.35,,,percent of total billed charges,,,0.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.49,,,percent of total billed charges,,,0.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.49,,,fee schedule,,,0.49,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,548.68,,,per diem,,,0.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.49,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,0.18,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.29,,,percent of total billed charges,,
TRAMADOL 50 MG TAB,2500017580,CDM,637,RC,904717961,NDC,999,EAPG,,,,outpatient,facility,50,UN,0.49,0.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAZODONE HCL 100 MG TAB,2500017600,CDM,637,RC,904686961,NDC,,,,,,inpatient,facility,100,UN,0.59,0.59,0.05,0.59,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,
TRAZODONE HCL 100 MG TAB,2500017600,CDM,637,RC,904686961,NDC,,,,,,outpatient,facility,100,UN,0.59,0.59,0.05,548.68,,0.42,,,percent of total billed charges,,,0.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.59,,,percent of total billed charges,,,0.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.59,,,fee schedule,,,0.59,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,0.35,,,percent of total billed charges,,,548.68,,,per diem,,,0.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.59,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,0.22,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.35,,,percent of total billed charges,,
TRAZODONE HCL 100 MG TAB,2500017600,CDM,637,RC,904686961,NDC,999,EAPG,,,,outpatient,facility,100,UN,0.59,0.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRAZODONE HCL 50 MG TAB,2500017601,CDM,637,RC,904686861,NDC,,,,,,inpatient,facility,50,UN,0.39,0.39,0.03,0.39,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,
TRAZODONE HCL 50 MG TAB,2500017601,CDM,637,RC,904686861,NDC,,,,,,outpatient,facility,50,UN,0.39,0.39,0.03,548.68,,0.28,,,percent of total billed charges,,,0.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.39,,,percent of total billed charges,,,0.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.14,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.39,,,fee schedule,,,0.39,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,548.68,,,per diem,,,0.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.39,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,0.14,,,percent of total billed charges,,,0.14,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.23,,,percent of total billed charges,,
TRAZODONE HCL 50 MG TAB,2500017601,CDM,637,RC,904686861,NDC,999,EAPG,,,,outpatient,facility,50,UN,0.39,0.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIAMCINOLONE 0.1  CR 15 GM,2500017624,CDM,637,RC,6787725115,NDC,,,,,,inpatient,facility,15,UN,19.24,19.24,1.54,19.24,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,19.24,,,percent of total billed charges,,,9.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.54,,,percent of total billed charges,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,16.35,,,percent of total billed charges,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,10.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.34,,,percent of total billed charges,,
TRIAMCINOLONE 0.1  CR 15 GM,2500017624,CDM,637,RC,6787725115,NDC,,,,,,outpatient,facility,15,UN,19.24,19.24,1.54,548.68,,13.64,,,percent of total billed charges,,,4.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,19.24,,,percent of total billed charges,,,12.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,13.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,13.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.04,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,19.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,19.24,,,fee schedule,,,19.24,,,percent of total billed charges,,,,,,,,,19.24,,,percent of total billed charges,,,11.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.71,,,percent of total billed charges,,,,,,,,,,,,,,,10.39,,,percent of total billed charges,,,10,,,percent of total billed charges,,,10.58,,,percent of total billed charges,,,,,,,,,11.35,,,percent of total billed charges,,,548.68,,,per diem,,,19.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,19.24,,,percent of total billed charges,,,16.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.22,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.98,,,percent of total billed charges,,,15.57,,,percent of total billed charges,,,,,,,,,,,,,,,7.7,,,percent of total billed charges,,,,,,,,,7.12,,,percent of total billed charges,,,7.12,,,percent of total billed charges,,,,,,,,,19.24,,,percent of total billed charges,,,19.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.54,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,,,,,,,,,,,,,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,,,,,,,17.9,,,percent of total billed charges,,,,,,,,,,,,,,,17.9,,,percent of total billed charges,,,17.9,,,percent of total billed charges,,,17.9,,,percent of total billed charges,,,14.43,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,19.24,,,percent of total billed charges,,,,,,,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.62,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.34,,,percent of total billed charges,,
TRIAMCINOLONE 0.1  CR 15 GM,2500017624,CDM,637,RC,6787725115,NDC,999,EAPG,,,,outpatient,facility,15,UN,19.24,19.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIAMCINOLONE 0.1  ORABAS 5GM,2500017626,CDM,637,RC,713065540,NDC,,,,,,inpatient,facility,5,UN,274,274,21.92,274,,,,,,,,,,,,,,274,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274,,,percent of total billed charges,,,,,,,,,274,,,percent of total billed charges,,,139.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.4,,,percent of total billed charges,,,,,,,,,,,,,,,274,,,percent of total billed charges,,,232.9,,,percent of total billed charges,,,,,,,,,,,,,,,274,,,percent of total billed charges,,,145.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,274,,,percent of total billed charges,,,,,,,,,,,,,,,21.92,,,percent of total billed charges,,,274,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,274,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.44,,,percent of total billed charges,,
TRIAMCINOLONE 0.1  ORABAS 5GM,2500017626,CDM,637,RC,713065540,NDC,,,,,,outpatient,facility,5,UN,274,274,21.92,548.68,,194.29,,,percent of total billed charges,,,66.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,274,,,percent of total billed charges,,,171.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,192.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,192.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,274,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,100.28,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,274,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,274,,,fee schedule,,,274,,,percent of total billed charges,,,,,,,,,274,,,percent of total billed charges,,,167.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.22,,,percent of total billed charges,,,,,,,,,,,,,,,147.96,,,percent of total billed charges,,,142.48,,,percent of total billed charges,,,150.7,,,percent of total billed charges,,,,,,,,,161.66,,,percent of total billed charges,,,548.68,,,per diem,,,274,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,274,,,percent of total billed charges,,,232.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,145.52,,,percent of total billed charges,,,274,,,percent of total billed charges,,,274,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.84,,,percent of total billed charges,,,221.72,,,percent of total billed charges,,,,,,,,,,,,,,,109.6,,,percent of total billed charges,,,,,,,,,101.38,,,percent of total billed charges,,,101.38,,,percent of total billed charges,,,,,,,,,274,,,percent of total billed charges,,,274,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,274,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.92,,,percent of total billed charges,,,274,,,percent of total billed charges,,,,,,,,,,,,,,,274,,,percent of total billed charges,,,274,,,percent of total billed charges,,,,,,,,,254.87,,,percent of total billed charges,,,,,,,,,,,,,,,254.87,,,percent of total billed charges,,,254.87,,,percent of total billed charges,,,254.87,,,percent of total billed charges,,,205.5,,,percent of total billed charges,,,274,,,percent of total billed charges,,,274,,,percent of total billed charges,,,274,,,percent of total billed charges,,,,,,,,,192.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,161.44,,,percent of total billed charges,,
TRIAMCINOLONE 0.1  ORABAS 5GM,2500017626,CDM,637,RC,713065540,NDC,999,EAPG,,,,outpatient,facility,5,UN,274,274,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIAMCINOLONE 0.1  OINT 15GM,2500017627,CDM,637,RC,3334233315,NDC,,,,,,inpatient,facility,15,UN,18.38,18.38,1.47,18.38,,,,,,,,,,,,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.38,,,percent of total billed charges,,,,,,,,,18.38,,,percent of total billed charges,,,9.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.03,,,percent of total billed charges,,,,,,,,,,,,,,,18.38,,,percent of total billed charges,,,15.62,,,percent of total billed charges,,,,,,,,,,,,,,,18.38,,,percent of total billed charges,,,9.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.83,,,percent of total billed charges,,
TRIAMCINOLONE 0.1  OINT 15GM,2500017627,CDM,637,RC,3334233315,NDC,,,,,,outpatient,facility,15,UN,18.38,18.38,1.47,548.68,,13.03,,,percent of total billed charges,,,4.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,18.38,,,percent of total billed charges,,,11.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,12.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,12.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,18.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,18.38,,,fee schedule,,,18.38,,,percent of total billed charges,,,,,,,,,18.38,,,percent of total billed charges,,,11.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,9.93,,,percent of total billed charges,,,9.56,,,percent of total billed charges,,,10.11,,,percent of total billed charges,,,,,,,,,10.84,,,percent of total billed charges,,,548.68,,,per diem,,,18.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,18.38,,,percent of total billed charges,,,15.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.76,,,percent of total billed charges,,,18.38,,,percent of total billed charges,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.4,,,percent of total billed charges,,,14.87,,,percent of total billed charges,,,,,,,,,,,,,,,7.35,,,percent of total billed charges,,,,,,,,,6.8,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,18.38,,,percent of total billed charges,,,18.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.47,,,percent of total billed charges,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,18.38,,,percent of total billed charges,,,18.38,,,percent of total billed charges,,,,,,,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,17.1,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,13.79,,,percent of total billed charges,,,18.38,,,percent of total billed charges,,,18.38,,,percent of total billed charges,,,18.38,,,percent of total billed charges,,,,,,,,,12.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.83,,,percent of total billed charges,,
TRIAMCINOLONE 0.1  OINT 15GM,2500017627,CDM,637,RC,3334233315,NDC,999,EAPG,,,,outpatient,facility,15,UN,18.38,18.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIAMCINOLONE 0.1  OINT 80GM,2500017628,CDM,637,RC,3334233380,NDC,,,,,,inpatient,facility,80,UN,41.84,41.84,3.35,41.84,,,,,,,,,,,,,,41.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.84,,,percent of total billed charges,,,,,,,,,41.84,,,percent of total billed charges,,,21.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.1,,,percent of total billed charges,,,,,,,,,,,,,,,41.84,,,percent of total billed charges,,,35.56,,,percent of total billed charges,,,,,,,,,,,,,,,41.84,,,percent of total billed charges,,,22.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,41.84,,,percent of total billed charges,,,,,,,,,,,,,,,3.35,,,percent of total billed charges,,,41.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.65,,,percent of total billed charges,,
TRIAMCINOLONE 0.1  OINT 80GM,2500017628,CDM,637,RC,3334233380,NDC,,,,,,outpatient,facility,80,UN,41.84,41.84,3.35,548.68,,29.67,,,percent of total billed charges,,,10.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,41.84,,,percent of total billed charges,,,26.22,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,29.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,29.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,41.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,15.31,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,41.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,41.84,,,fee schedule,,,41.84,,,percent of total billed charges,,,,,,,,,41.84,,,percent of total billed charges,,,25.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.81,,,percent of total billed charges,,,,,,,,,,,,,,,22.59,,,percent of total billed charges,,,21.76,,,percent of total billed charges,,,23.01,,,percent of total billed charges,,,,,,,,,24.69,,,percent of total billed charges,,,548.68,,,per diem,,,41.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,41.84,,,percent of total billed charges,,,35.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.22,,,percent of total billed charges,,,41.84,,,percent of total billed charges,,,41.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.23,,,percent of total billed charges,,,33.86,,,percent of total billed charges,,,,,,,,,,,,,,,16.74,,,percent of total billed charges,,,,,,,,,15.48,,,percent of total billed charges,,,15.48,,,percent of total billed charges,,,,,,,,,41.84,,,percent of total billed charges,,,41.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,41.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.35,,,percent of total billed charges,,,41.84,,,percent of total billed charges,,,,,,,,,,,,,,,41.84,,,percent of total billed charges,,,41.84,,,percent of total billed charges,,,,,,,,,38.92,,,percent of total billed charges,,,,,,,,,,,,,,,38.92,,,percent of total billed charges,,,38.92,,,percent of total billed charges,,,38.92,,,percent of total billed charges,,,31.38,,,percent of total billed charges,,,41.84,,,percent of total billed charges,,,41.84,,,percent of total billed charges,,,41.84,,,percent of total billed charges,,,,,,,,,29.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.92,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,24.65,,,percent of total billed charges,,
TRIAMCINOLONE 0.1  OINT 80GM,2500017628,CDM,637,RC,3334233380,NDC,999,EAPG,,,,outpatient,facility,80,UN,41.84,41.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIAMCINOLONE 0.5  CR 15 GM,2500017630,CDM,637,RC,6787731815,NDC,,,,,,inpatient,facility,15,UN,37.42,37.42,2.99,37.42,,,,,,,,,,,,,,37.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.42,,,percent of total billed charges,,,,,,,,,37.42,,,percent of total billed charges,,,19.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.45,,,percent of total billed charges,,,,,,,,,,,,,,,37.42,,,percent of total billed charges,,,31.81,,,percent of total billed charges,,,,,,,,,,,,,,,37.42,,,percent of total billed charges,,,19.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,37.42,,,percent of total billed charges,,,,,,,,,,,,,,,2.99,,,percent of total billed charges,,,37.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.05,,,percent of total billed charges,,
TRIAMCINOLONE 0.5  CR 15 GM,2500017630,CDM,637,RC,6787731815,NDC,,,,,,outpatient,facility,15,UN,37.42,37.42,2.99,548.68,,26.53,,,percent of total billed charges,,,9.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,37.42,,,percent of total billed charges,,,23.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,26.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,26.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,37.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,13.7,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,37.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,37.42,,,fee schedule,,,37.42,,,percent of total billed charges,,,,,,,,,37.42,,,percent of total billed charges,,,22.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.66,,,percent of total billed charges,,,,,,,,,,,,,,,20.21,,,percent of total billed charges,,,19.46,,,percent of total billed charges,,,20.58,,,percent of total billed charges,,,,,,,,,22.08,,,percent of total billed charges,,,548.68,,,per diem,,,37.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,37.42,,,percent of total billed charges,,,31.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.87,,,percent of total billed charges,,,37.42,,,percent of total billed charges,,,37.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.24,,,percent of total billed charges,,,30.28,,,percent of total billed charges,,,,,,,,,,,,,,,14.97,,,percent of total billed charges,,,,,,,,,13.85,,,percent of total billed charges,,,13.85,,,percent of total billed charges,,,,,,,,,37.42,,,percent of total billed charges,,,37.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,37.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.99,,,percent of total billed charges,,,37.42,,,percent of total billed charges,,,,,,,,,,,,,,,37.42,,,percent of total billed charges,,,37.42,,,percent of total billed charges,,,,,,,,,34.81,,,percent of total billed charges,,,,,,,,,,,,,,,34.81,,,percent of total billed charges,,,34.81,,,percent of total billed charges,,,34.81,,,percent of total billed charges,,,28.07,,,percent of total billed charges,,,37.42,,,percent of total billed charges,,,37.42,,,percent of total billed charges,,,37.42,,,percent of total billed charges,,,,,,,,,26.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,22.05,,,percent of total billed charges,,
TRIAMCINOLONE 0.5  CR 15 GM,2500017630,CDM,637,RC,6787731815,NDC,999,EAPG,,,,outpatient,facility,15,UN,37.42,37.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIAMTERENE/HCTZ 37.5-25MG TAB,2500017651,CDM,637,RC,6050526561,NDC,,,,,,inpatient,facility,1,UN,1.29,1.29,0.1,1.29,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,
TRIAMTERENE/HCTZ 37.5-25MG TAB,2500017651,CDM,637,RC,6050526561,NDC,,,,,,outpatient,facility,1,UN,1.29,1.29,0.1,548.68,,0.91,,,percent of total billed charges,,,0.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.29,,,percent of total billed charges,,,0.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.47,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.29,,,fee schedule,,,1.29,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,0.76,,,percent of total billed charges,,,548.68,,,per diem,,,1.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.29,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,0.48,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,1.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,0.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.76,,,percent of total billed charges,,
TRIAMTERENE/HCTZ 37.5-25MG TAB,2500017651,CDM,637,RC,6050526561,NDC,999,EAPG,,,,outpatient,facility,1,UN,1.29,1.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIHEXYPHENIDYL 2 MG TAB,2500017734,CDM,637,RC,591533501,NDC,,,,,,inpatient,facility,2,UN,0.59,0.59,0.05,0.59,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,
TRIHEXYPHENIDYL 2 MG TAB,2500017734,CDM,637,RC,591533501,NDC,,,,,,outpatient,facility,2,UN,0.59,0.59,0.05,548.68,,0.42,,,percent of total billed charges,,,0.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.59,,,percent of total billed charges,,,0.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.59,,,fee schedule,,,0.59,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,0.35,,,percent of total billed charges,,,548.68,,,per diem,,,0.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.59,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,0.22,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.35,,,percent of total billed charges,,
TRIHEXYPHENIDYL 2 MG TAB,2500017734,CDM,637,RC,591533501,NDC,999,EAPG,,,,outpatient,facility,2,UN,0.59,0.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIMETHOPRIM 100 MG TAB,2500017780,CDM,637,RC,5140725701,NDC,,,,,,inpatient,facility,100,UN,1.68,1.68,0.13,1.68,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,
TRIMETHOPRIM 100 MG TAB,2500017780,CDM,637,RC,5140725701,NDC,,,,,,outpatient,facility,100,UN,1.68,1.68,0.13,548.68,,1.19,,,percent of total billed charges,,,0.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.68,,,percent of total billed charges,,,1.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.68,,,fee schedule,,,1.68,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,548.68,,,per diem,,,1.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.68,,,percent of total billed charges,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,1.56,,,percent of total billed charges,,,,,,,,,,,,,,,1.56,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,1.26,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.99,,,percent of total billed charges,,
TRIMETHOPRIM 100 MG TAB,2500017780,CDM,637,RC,5140725701,NDC,999,EAPG,,,,outpatient,facility,100,UN,1.68,1.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIMETHOPRIM/SULFAMETH 20 ML,2500017792,CDM,637,RC,121085340,NDC,,,,,,inpatient,facility,20,UN,59.07,59.07,4.73,59.07,,,,,,,,,,,,,,59.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.07,,,percent of total billed charges,,,,,,,,,59.07,,,percent of total billed charges,,,30.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.44,,,percent of total billed charges,,,,,,,,,,,,,,,59.07,,,percent of total billed charges,,,50.21,,,percent of total billed charges,,,,,,,,,,,,,,,59.07,,,percent of total billed charges,,,31.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,59.07,,,percent of total billed charges,,,,,,,,,,,,,,,4.73,,,percent of total billed charges,,,59.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.8,,,percent of total billed charges,,
TRIMETHOPRIM/SULFAMETH 20 ML,2500017792,CDM,637,RC,121085340,NDC,,,,,,outpatient,facility,20,UN,59.07,59.07,4.73,548.68,,41.89,,,percent of total billed charges,,,14.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,59.07,,,percent of total billed charges,,,37.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,41.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,41.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,59.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,21.62,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,59.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,59.07,,,fee schedule,,,59.07,,,percent of total billed charges,,,,,,,,,59.07,,,percent of total billed charges,,,36.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.09,,,percent of total billed charges,,,,,,,,,,,,,,,31.9,,,percent of total billed charges,,,30.72,,,percent of total billed charges,,,32.49,,,percent of total billed charges,,,,,,,,,34.85,,,percent of total billed charges,,,548.68,,,per diem,,,59.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,59.07,,,percent of total billed charges,,,50.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.37,,,percent of total billed charges,,,59.07,,,percent of total billed charges,,,59.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.85,,,percent of total billed charges,,,47.8,,,percent of total billed charges,,,,,,,,,,,,,,,23.63,,,percent of total billed charges,,,,,,,,,21.86,,,percent of total billed charges,,,21.86,,,percent of total billed charges,,,,,,,,,59.07,,,percent of total billed charges,,,59.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,59.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.73,,,percent of total billed charges,,,59.07,,,percent of total billed charges,,,,,,,,,,,,,,,59.07,,,percent of total billed charges,,,59.07,,,percent of total billed charges,,,,,,,,,54.95,,,percent of total billed charges,,,,,,,,,,,,,,,54.95,,,percent of total billed charges,,,54.95,,,percent of total billed charges,,,54.95,,,percent of total billed charges,,,44.3,,,percent of total billed charges,,,59.07,,,percent of total billed charges,,,59.07,,,percent of total billed charges,,,59.07,,,percent of total billed charges,,,,,,,,,41.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,34.8,,,percent of total billed charges,,
TRIMETHOPRIM/SULFAMETH 20 ML,2500017792,CDM,637,RC,121085340,NDC,999,EAPG,,,,outpatient,facility,20,UN,59.07,59.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRIMETHOPRIM/SULFAMETH DS TAB,2500017795,CDM,637,RC,904272561,NDC,,,,,,inpatient,facility,1,UN,0.63,0.63,0.05,0.63,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,0.63,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,
TRIMETHOPRIM/SULFAMETH DS TAB,2500017795,CDM,637,RC,904272561,NDC,,,,,,outpatient,facility,1,UN,0.63,0.63,0.05,548.68,,0.45,,,percent of total billed charges,,,0.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.63,,,percent of total billed charges,,,0.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.63,,,fee schedule,,,0.63,,,percent of total billed charges,,,,,,,,,0.63,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,0.33,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,,,,,,,0.37,,,percent of total billed charges,,,548.68,,,per diem,,,0.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.63,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,0.23,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,0.63,,,percent of total billed charges,,,0.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.37,,,percent of total billed charges,,
TRIMETHOPRIM/SULFAMETH DS TAB,2500017795,CDM,637,RC,904272561,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.63,0.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TROPICAMIDE 0.5  OP SOL 15ML,2500017860,CDM,637,RC,1747810112,NDC,,,,,,inpatient,facility,15,UN,33,33,2.64,33,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,16.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,17.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.44,,,percent of total billed charges,,
TROPICAMIDE 0.5  OP SOL 15ML,2500017860,CDM,637,RC,1747810112,NDC,,,,,,outpatient,facility,15,UN,33,33,2.64,548.68,,23.4,,,percent of total billed charges,,,8.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,33,,,percent of total billed charges,,,20.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,23.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,23.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,33,,,fee schedule,,,33,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,20.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.51,,,percent of total billed charges,,,,,,,,,,,,,,,17.82,,,percent of total billed charges,,,17.16,,,percent of total billed charges,,,18.15,,,percent of total billed charges,,,,,,,,,19.47,,,percent of total billed charges,,,548.68,,,per diem,,,33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,33,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.53,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.26,,,percent of total billed charges,,,26.7,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,12.21,,,percent of total billed charges,,,12.21,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.64,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,30.7,,,percent of total billed charges,,,,,,,,,,,,,,,30.7,,,percent of total billed charges,,,30.7,,,percent of total billed charges,,,30.7,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,23.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,19.44,,,percent of total billed charges,,
TROPICAMIDE 0.5  OP SOL 15ML,2500017860,CDM,637,RC,1747810112,NDC,999,EAPG,,,,outpatient,facility,15,UN,33,33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TROPICAMIDE 1  OP SOLN 15ML,2500017861,CDM,637,RC,1747810212,NDC,,,,,,inpatient,facility,15,UN,35.15,35.15,2.81,35.15,,,,,,,,,,,,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.15,,,percent of total billed charges,,,,,,,,,35.15,,,percent of total billed charges,,,17.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,35.15,,,percent of total billed charges,,,29.88,,,percent of total billed charges,,,,,,,,,,,,,,,35.15,,,percent of total billed charges,,,18.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.71,,,percent of total billed charges,,
TROPICAMIDE 1  OP SOLN 15ML,2500017861,CDM,637,RC,1747810212,NDC,,,,,,outpatient,facility,15,UN,35.15,35.15,2.81,548.68,,24.92,,,percent of total billed charges,,,8.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,35.15,,,percent of total billed charges,,,22.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,24.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,24.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.86,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,35.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,35.15,,,fee schedule,,,35.15,,,percent of total billed charges,,,,,,,,,35.15,,,percent of total billed charges,,,21.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.04,,,percent of total billed charges,,,,,,,,,,,,,,,18.98,,,percent of total billed charges,,,18.28,,,percent of total billed charges,,,19.33,,,percent of total billed charges,,,,,,,,,20.74,,,percent of total billed charges,,,548.68,,,per diem,,,35.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,35.15,,,percent of total billed charges,,,29.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.67,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.71,,,percent of total billed charges,,,28.44,,,percent of total billed charges,,,,,,,,,,,,,,,14.06,,,percent of total billed charges,,,,,,,,,13.01,,,percent of total billed charges,,,13.01,,,percent of total billed charges,,,,,,,,,35.15,,,percent of total billed charges,,,35.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.81,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,35.15,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,32.7,,,percent of total billed charges,,,,,,,,,,,,,,,32.7,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,32.7,,,percent of total billed charges,,,26.36,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,24.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,20.71,,,percent of total billed charges,,
TROPICAMIDE 1  OP SOLN 15ML,2500017861,CDM,637,RC,1747810212,NDC,999,EAPG,,,,outpatient,facility,15,UN,35.15,35.15,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TROPICAMIDE 1  OP SOLN 3 ML,2500017863,CDM,637,RC,6131435501,NDC,,,,,,inpatient,facility,3,UN,46.2,46.2,3.7,46.2,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,23.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.72,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,39.27,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,24.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.22,,,percent of total billed charges,,
TROPICAMIDE 1  OP SOLN 3 ML,2500017863,CDM,637,RC,6131435501,NDC,,,,,,outpatient,facility,3,UN,46.2,46.2,3.7,548.68,,32.76,,,percent of total billed charges,,,11.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,46.2,,,percent of total billed charges,,,28.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,32.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,32.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,16.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,46.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,46.2,,,fee schedule,,,46.2,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,28.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.92,,,percent of total billed charges,,,,,,,,,,,,,,,24.95,,,percent of total billed charges,,,24.02,,,percent of total billed charges,,,25.41,,,percent of total billed charges,,,,,,,,,27.26,,,percent of total billed charges,,,548.68,,,per diem,,,46.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,46.2,,,percent of total billed charges,,,39.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.54,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.17,,,percent of total billed charges,,,37.39,,,percent of total billed charges,,,,,,,,,,,,,,,18.48,,,percent of total billed charges,,,,,,,,,17.09,,,percent of total billed charges,,,17.09,,,percent of total billed charges,,,,,,,,,46.2,,,percent of total billed charges,,,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,46.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.7,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,,,,,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,42.98,,,percent of total billed charges,,,,,,,,,,,,,,,42.98,,,percent of total billed charges,,,42.98,,,percent of total billed charges,,,42.98,,,percent of total billed charges,,,34.65,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,46.2,,,percent of total billed charges,,,,,,,,,32.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,27.22,,,percent of total billed charges,,
TROPICAMIDE 1  OP SOLN 3 ML,2500017863,CDM,637,RC,6131435501,NDC,999,EAPG,,,,outpatient,facility,3,UN,46.2,46.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TUBERCULIN PPD 5 TU/0.1 ML 1ML,2500017893,CDM,250,RC,4928175221,NDC,,,,,,inpatient,facility,0.1,UN,30.26,30.26,2.42,30.26,,,,,,,,,,,,,,30.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.26,,,percent of total billed charges,,,,,,,,,30.26,,,percent of total billed charges,,,15.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.16,,,percent of total billed charges,,,,,,,,,,,,,,,30.26,,,percent of total billed charges,,,25.72,,,percent of total billed charges,,,,,,,,,,,,,,,30.26,,,percent of total billed charges,,,16.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,30.26,,,percent of total billed charges,,,,,,,,,,,,,,,2.42,,,percent of total billed charges,,,30.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.83,,,percent of total billed charges,,
TUBERCULIN PPD 5 TU/0.1 ML 1ML,2500017893,CDM,250,RC,4928175221,NDC,,,,,,outpatient,facility,0.1,UN,30.26,30.26,2.42,548.68,,21.46,,,percent of total billed charges,,,7.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,30.26,,,percent of total billed charges,,,18.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,21.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,21.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,30.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,30.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,30.26,,,fee schedule,,,30.26,,,percent of total billed charges,,,,,,,,,30.26,,,percent of total billed charges,,,18.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,17.85,,,percent of total billed charges,,,548.68,,,per diem,,,30.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,30.26,,,percent of total billed charges,,,25.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.07,,,percent of total billed charges,,,30.26,,,percent of total billed charges,,,30.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.41,,,percent of total billed charges,,,24.49,,,percent of total billed charges,,,,,,,,,,,,,,,12.1,,,percent of total billed charges,,,,,,,,,12.1,,,percent of total billed charges,,,12.1,,,percent of total billed charges,,,,,,,,,30.26,,,percent of total billed charges,,,30.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.42,,,percent of total billed charges,,,30.26,,,percent of total billed charges,,,,,,,,,,,,,,,30.26,,,percent of total billed charges,,,30.26,,,percent of total billed charges,,,,,,,,,12.1,,,percent of total billed charges,,,,,,,,,,,,,,,12.1,,,percent of total billed charges,,,12.1,,,percent of total billed charges,,,12.1,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,30.26,,,percent of total billed charges,,,30.26,,,percent of total billed charges,,,30.26,,,percent of total billed charges,,,,,,,,,21.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.83,,,percent of total billed charges,,
TUBERCULIN PPD 5 TU/0.1 ML 1ML,2500017893,CDM,250,RC,4928175221,NDC,999,EAPG,,,,outpatient,facility,0.1,UN,30.26,30.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
URSODIOL 300 MG CAP,2500017983,CDM,637,RC,6923815401,NDC,,,,,,inpatient,facility,300,UN,24.25,24.25,1.94,24.25,,,,,,,,,,,,,,24.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.25,,,percent of total billed charges,,,,,,,,,24.25,,,percent of total billed charges,,,12.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.55,,,percent of total billed charges,,,,,,,,,,,,,,,24.25,,,percent of total billed charges,,,20.61,,,percent of total billed charges,,,,,,,,,,,,,,,24.25,,,percent of total billed charges,,,12.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,24.25,,,percent of total billed charges,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.29,,,percent of total billed charges,,
URSODIOL 300 MG CAP,2500017983,CDM,637,RC,6923815401,NDC,,,,,,outpatient,facility,300,UN,24.25,24.25,1.94,548.68,,17.2,,,percent of total billed charges,,,5.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,24.25,,,percent of total billed charges,,,15.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,17.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,17.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,24.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.88,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,24.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,24.25,,,fee schedule,,,24.25,,,percent of total billed charges,,,,,,,,,24.25,,,percent of total billed charges,,,14.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.28,,,percent of total billed charges,,,,,,,,,,,,,,,13.1,,,percent of total billed charges,,,12.61,,,percent of total billed charges,,,13.34,,,percent of total billed charges,,,,,,,,,14.31,,,percent of total billed charges,,,548.68,,,per diem,,,24.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,24.25,,,percent of total billed charges,,,20.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.88,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.36,,,percent of total billed charges,,,19.62,,,percent of total billed charges,,,,,,,,,,,,,,,9.7,,,percent of total billed charges,,,,,,,,,8.97,,,percent of total billed charges,,,8.97,,,percent of total billed charges,,,,,,,,,24.25,,,percent of total billed charges,,,24.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.94,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,,,,,,,,,,,,,24.25,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,,,,,,,22.56,,,percent of total billed charges,,,,,,,,,,,,,,,22.56,,,percent of total billed charges,,,22.56,,,percent of total billed charges,,,22.56,,,percent of total billed charges,,,18.19,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,24.25,,,percent of total billed charges,,,,,,,,,17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.29,,,percent of total billed charges,,
URSODIOL 300 MG CAP,2500017983,CDM,637,RC,6923815401,NDC,999,EAPG,,,,outpatient,facility,300,UN,24.25,24.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALACYCLOVIR HCL 500 MG TAB,2500017990,CDM,637,RC,904656561,NDC,,,,,,inpatient,facility,500,UN,8.05,8.05,0.64,8.05,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,8.05,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.83,,,percent of total billed charges,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,6.84,,,percent of total billed charges,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,4.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.74,,,percent of total billed charges,,
VALACYCLOVIR HCL 500 MG TAB,2500017990,CDM,637,RC,904656561,NDC,,,,,,outpatient,facility,500,UN,8.05,8.05,0.64,548.68,,5.71,,,percent of total billed charges,,,1.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.05,,,percent of total billed charges,,,5.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.95,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.05,,,fee schedule,,,8.05,,,percent of total billed charges,,,,,,,,,8.05,,,percent of total billed charges,,,4.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.74,,,percent of total billed charges,,,,,,,,,,,,,,,4.35,,,percent of total billed charges,,,4.19,,,percent of total billed charges,,,4.43,,,percent of total billed charges,,,,,,,,,4.75,,,percent of total billed charges,,,548.68,,,per diem,,,8.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.05,,,percent of total billed charges,,,6.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.43,,,percent of total billed charges,,,6.51,,,percent of total billed charges,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,,,,,,,2.98,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,,,,,,,8.05,,,percent of total billed charges,,,8.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.64,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,7.49,,,percent of total billed charges,,,6.04,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,8.05,,,percent of total billed charges,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.74,,,percent of total billed charges,,
VALACYCLOVIR HCL 500 MG TAB,2500017990,CDM,637,RC,904656561,NDC,999,EAPG,,,,outpatient,facility,500,UN,8.05,8.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALPROATE SOD 100MG/ML 5ML INJ,2500018000,CDM,250,RC,J3490,HCPCS,6332349405,NDC,,,,inpatient,facility,5,UN,22.11,22.11,1.77,22.11,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,22.11,,,percent of total billed charges,,,11.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,18.79,,,percent of total billed charges,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,11.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.03,,,percent of total billed charges,,
VALPROATE SOD 100MG/ML 5ML INJ,2500018000,CDM,250,RC,J3490,HCPCS,6332349405,NDC,,,,outpatient,facility,5,UN,22.11,22.11,1.2,548.68,,15.68,,,percent of total billed charges,,,5.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,22.11,,,percent of total billed charges,,,13.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,15.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,15.54,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.09,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,22.11,,,fee schedule,,,22.11,,,percent of total billed charges,,,,,,,,,22.11,,,percent of total billed charges,,,13.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.75,,,percent of total billed charges,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,13.04,,,percent of total billed charges,,,548.68,,,per diem,,,22.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,22.11,,,percent of total billed charges,,,18.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.74,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.92,,,percent of total billed charges,,,17.89,,,percent of total billed charges,,,,,,,,,,,,,,,8.84,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22.11,,,percent of total billed charges,,,22.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.77,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,16.58,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,15.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.03,,,percent of total billed charges,,
VALPROATE SOD 100MG/ML 5ML INJ,2500018000,CDM,250,RC,J3490,HCPCS,6332349405,NDC,435,EAPG,,outpatient,facility,5,UN,22.11,22.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALPROIC ACID 250 MG CAP,2500018010,CDM,637,RC,6945215020,NDC,,,,,,inpatient,facility,250,UN,2.77,2.77,0.22,2.77,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,
VALPROIC ACID 250 MG CAP,2500018010,CDM,637,RC,6945215020,NDC,,,,,,outpatient,facility,250,UN,2.77,2.77,0.22,548.68,,1.96,,,percent of total billed charges,,,0.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.77,,,percent of total billed charges,,,1.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.77,,,fee schedule,,,2.77,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,1.63,,,percent of total billed charges,,,548.68,,,per diem,,,2.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.77,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.22,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,2.58,,,percent of total billed charges,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,2.58,,,percent of total billed charges,,,2.58,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.63,,,percent of total billed charges,,
VALPROIC ACID 250 MG CAP,2500018010,CDM,637,RC,6945215020,NDC,999,EAPG,,,,outpatient,facility,250,UN,2.77,2.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALPROIC ACID 250MG/5ML  UDC,2500018014,CDM,637,RC,121467500,NDC,,,,,,inpatient,facility,5,UN,4.95,4.95,0.4,4.95,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,4.95,,,percent of total billed charges,,,2.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,2.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,
VALPROIC ACID 250MG/5ML  UDC,2500018014,CDM,637,RC,121467500,NDC,,,,,,outpatient,facility,5,UN,4.95,4.95,0.4,548.68,,3.51,,,percent of total billed charges,,,1.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.95,,,percent of total billed charges,,,3.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.81,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.95,,,fee schedule,,,4.95,,,percent of total billed charges,,,,,,,,,4.95,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,,,,,,,2.92,,,percent of total billed charges,,,548.68,,,per diem,,,4.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.95,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.63,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.34,,,percent of total billed charges,,,4.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,,,,,,,1.83,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,,,,,,,4.95,,,percent of total billed charges,,,4.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.4,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,4.6,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,,,,,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.92,,,percent of total billed charges,,
VALPROIC ACID 250MG/5ML  UDC,2500018014,CDM,637,RC,121467500,NDC,999,EAPG,,,,outpatient,facility,5,UN,4.95,4.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 125 MG CAP,2500018030,CDM,637,RC,121086720,NDC,,,,,,inpatient,facility,125,UN,103.32,103.32,8.27,103.32,,,,,,,,,,,,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.32,,,percent of total billed charges,,,,,,,,,103.32,,,percent of total billed charges,,,52.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.99,,,percent of total billed charges,,,,,,,,,,,,,,,103.32,,,percent of total billed charges,,,87.82,,,percent of total billed charges,,,,,,,,,,,,,,,103.32,,,percent of total billed charges,,,54.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,8.27,,,percent of total billed charges,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.88,,,percent of total billed charges,,
VANCOMYCIN 125 MG CAP,2500018030,CDM,637,RC,121086720,NDC,,,,,,outpatient,facility,125,UN,103.32,103.32,8.27,548.68,,73.26,,,percent of total billed charges,,,25.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,103.32,,,percent of total billed charges,,,64.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,72.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,72.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,37.82,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,103.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,103.32,,,fee schedule,,,103.32,,,percent of total billed charges,,,,,,,,,103.32,,,percent of total billed charges,,,63.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.62,,,percent of total billed charges,,,,,,,,,,,,,,,55.79,,,percent of total billed charges,,,53.73,,,percent of total billed charges,,,56.83,,,percent of total billed charges,,,,,,,,,60.96,,,percent of total billed charges,,,548.68,,,per diem,,,103.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,103.32,,,percent of total billed charges,,,87.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,103.32,,,percent of total billed charges,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.7,,,percent of total billed charges,,,83.61,,,percent of total billed charges,,,,,,,,,,,,,,,41.33,,,percent of total billed charges,,,,,,,,,38.23,,,percent of total billed charges,,,38.23,,,percent of total billed charges,,,,,,,,,103.32,,,percent of total billed charges,,,103.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,103.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.27,,,percent of total billed charges,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,103.32,,,percent of total billed charges,,,103.32,,,percent of total billed charges,,,,,,,,,96.11,,,percent of total billed charges,,,,,,,,,,,,,,,96.11,,,percent of total billed charges,,,96.11,,,percent of total billed charges,,,96.11,,,percent of total billed charges,,,77.49,,,percent of total billed charges,,,103.32,,,percent of total billed charges,,,103.32,,,percent of total billed charges,,,103.32,,,percent of total billed charges,,,,,,,,,72.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,60.88,,,percent of total billed charges,,
VANCOMYCIN 125 MG CAP,2500018030,CDM,637,RC,121086720,NDC,999,EAPG,,,,outpatient,facility,125,UN,103.32,103.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 125 MG/2.5 ML PFOS,2500018033,CDM,637,RC,6745733950,NDC,,,,,,inpatient,facility,2.5,UN,31.85,31.85,2.55,31.85,,,,,,,,,,,,,,31.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.85,,,percent of total billed charges,,,,,,,,,31.85,,,percent of total billed charges,,,16.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.11,,,percent of total billed charges,,,,,,,,,,,,,,,31.85,,,percent of total billed charges,,,27.07,,,percent of total billed charges,,,,,,,,,,,,,,,31.85,,,percent of total billed charges,,,16.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,31.85,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.77,,,percent of total billed charges,,
VANCOMYCIN 125 MG/2.5 ML PFOS,2500018033,CDM,637,RC,6745733950,NDC,,,,,,outpatient,facility,2.5,UN,31.85,31.85,2.55,548.68,,22.58,,,percent of total billed charges,,,7.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,31.85,,,percent of total billed charges,,,19.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,22.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,22.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,31.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.66,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,31.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,31.85,,,fee schedule,,,31.85,,,percent of total billed charges,,,,,,,,,31.85,,,percent of total billed charges,,,19.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.69,,,percent of total billed charges,,,,,,,,,,,,,,,17.2,,,percent of total billed charges,,,16.56,,,percent of total billed charges,,,17.52,,,percent of total billed charges,,,,,,,,,18.79,,,percent of total billed charges,,,548.68,,,per diem,,,31.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,31.85,,,percent of total billed charges,,,27.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.92,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.49,,,percent of total billed charges,,,25.77,,,percent of total billed charges,,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,,,,,,,11.78,,,percent of total billed charges,,,11.78,,,percent of total billed charges,,,,,,,,,31.85,,,percent of total billed charges,,,31.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.55,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,,,,,,,,,,,,,31.85,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,,,,,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,29.63,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,23.89,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,,,,,,,22.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.77,,,percent of total billed charges,,
VANCOMYCIN 125 MG/2.5 ML PFOS,2500018033,CDM,637,RC,6745733950,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,31.85,31.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 250 MG/5 ML PFOS,2500018035,CDM,637,RC,6745733950,NDC,,,,,,inpatient,facility,5,UN,31.85,31.85,2.55,31.85,,,,,,,,,,,,,,31.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.85,,,percent of total billed charges,,,,,,,,,31.85,,,percent of total billed charges,,,16.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.11,,,percent of total billed charges,,,,,,,,,,,,,,,31.85,,,percent of total billed charges,,,27.07,,,percent of total billed charges,,,,,,,,,,,,,,,31.85,,,percent of total billed charges,,,16.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,31.85,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.77,,,percent of total billed charges,,
VANCOMYCIN 250 MG/5 ML PFOS,2500018035,CDM,637,RC,6745733950,NDC,,,,,,outpatient,facility,5,UN,31.85,31.85,2.55,548.68,,22.58,,,percent of total billed charges,,,7.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,31.85,,,percent of total billed charges,,,19.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,22.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,22.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,31.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.66,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,31.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,31.85,,,fee schedule,,,31.85,,,percent of total billed charges,,,,,,,,,31.85,,,percent of total billed charges,,,19.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.69,,,percent of total billed charges,,,,,,,,,,,,,,,17.2,,,percent of total billed charges,,,16.56,,,percent of total billed charges,,,17.52,,,percent of total billed charges,,,,,,,,,18.79,,,percent of total billed charges,,,548.68,,,per diem,,,31.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,31.85,,,percent of total billed charges,,,27.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.92,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.49,,,percent of total billed charges,,,25.77,,,percent of total billed charges,,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,,,,,,,11.78,,,percent of total billed charges,,,11.78,,,percent of total billed charges,,,,,,,,,31.85,,,percent of total billed charges,,,31.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.55,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,,,,,,,,,,,,,31.85,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,,,,,,,29.63,,,percent of total billed charges,,,,,,,,,,,,,,,29.63,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,29.63,,,percent of total billed charges,,,23.89,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,,,,,,,22.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.77,,,percent of total billed charges,,
VANCOMYCIN 250 MG/5 ML PFOS,2500018035,CDM,637,RC,6745733950,NDC,999,EAPG,,,,outpatient,facility,5,UN,31.85,31.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VANCOMYCIN 1 GM INJ,2500018038,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,inpatient,facility,250,UN,53.07,53.07,4.25,53.07,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,53.07,,,percent of total billed charges,,,27.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.84,,,percent of total billed charges,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,45.11,,,percent of total billed charges,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,28.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,,,,,,,4.25,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.27,,,percent of total billed charges,,
VANCOMYCIN 1 GM INJ,2500018038,CDM,636,RC,J3370,HCPCS,6745734001,NDC,,,,outpatient,facility,250,UN,53.07,53.07,2.07,548.68,,37.63,,,percent of total billed charges,,,12.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,53.07,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,19.42,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,53.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,53.07,,,fee schedule,,,53.07,,,percent of total billed charges,,,,,,,,,53.07,,,percent of total billed charges,,,32.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,31.31,,,percent of total billed charges,,,548.68,,,per diem,,,53.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,53.07,,,percent of total billed charges,,,45.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.19,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.8,,,percent of total billed charges,,,42.94,,,percent of total billed charges,,,,,,,,,,,,,,,21.23,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,53.07,,,percent of total billed charges,,,53.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,53.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.25,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.07,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,,,,,,,37.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,31.27,,,percent of total billed charges,,
VANCOMYCIN 1 GM INJ,2500018038,CDM,636,RC,J3370,HCPCS,6745734001,NDC,496,EAPG,,outpatient,facility,250,UN,53.07,53.07,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VASOPRESSIN 20 U/ML INJ,2500018060,CDM,636,RC,J2599,HCPCS,4202316425,NDC,,,,inpatient,facility,1,UN,651.95,651.95,52.16,651.95,,,,,,,,,,,,,,651.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.95,,,percent of total billed charges,,,,,,,,,651.95,,,percent of total billed charges,,,332.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.17,,,percent of total billed charges,,,,,,,,,,,,,,,651.95,,,percent of total billed charges,,,554.16,,,percent of total billed charges,,,,,,,,,,,,,,,651.95,,,percent of total billed charges,,,346.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,260.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,651.95,,,percent of total billed charges,,,,,,,,,,,,,,,52.16,,,percent of total billed charges,,,651.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,651.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.13,,,percent of total billed charges,,
VASOPRESSIN 20 U/ML INJ,2500018060,CDM,636,RC,J2599,HCPCS,4202316425,NDC,,,,outpatient,facility,1,UN,651.95,651.95,1.63,651.95,,462.3,,,percent of total billed charges,,,159.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,651.95,,,percent of total billed charges,,,2.04,,,fee schedule,,,1.93,,,fee schedule,,,,,,,,,1.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,651.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,238.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,651.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,651.95,,,fee schedule,,,651.95,,,percent of total billed charges,,,,,,,,,651.95,,,percent of total billed charges,,,399.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,384.65,,,percent of total billed charges,,,548.68,,,per diem,,,651.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,651.95,,,percent of total billed charges,,,554.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,346.25,,,percent of total billed charges,,,651.95,,,percent of total billed charges,,,651.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,439.81,,,percent of total billed charges,,,527.56,,,percent of total billed charges,,,,,,,,,,,,,,,260.78,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,651.95,,,percent of total billed charges,,,651.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,651.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,52.16,,,percent of total billed charges,,,651.95,,,percent of total billed charges,,,,,,,,,,,,,,,651.95,,,percent of total billed charges,,,651.95,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.63,,,fee schedule,,,651.95,,,percent of total billed charges,,,651.95,,,percent of total billed charges,,,651.95,,,percent of total billed charges,,,,,,,,,457.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,384.13,,,percent of total billed charges,,
VASOPRESSIN 20 U/ML INJ,2500018060,CDM,636,RC,J2599,HCPCS,4202316425,NDC,999,EAPG,,outpatient,facility,1,UN,651.95,651.95,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VECURONIUM BR 10 MG/10 ML INJ,2500018070,CDM,250,RC,J3490,HCPCS,4733593144,NDC,,,,inpatient,facility,10,UN,28.05,28.05,2.24,28.05,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,28.05,,,percent of total billed charges,,,14.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.83,,,percent of total billed charges,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,23.84,,,percent of total billed charges,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,14.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.53,,,percent of total billed charges,,
VECURONIUM BR 10 MG/10 ML INJ,2500018070,CDM,250,RC,J3490,HCPCS,4733593144,NDC,,,,outpatient,facility,10,UN,28.05,28.05,1.2,548.68,,19.89,,,percent of total billed charges,,,6.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,28.05,,,percent of total billed charges,,,17.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,19.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,19.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.27,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,28.05,,,fee schedule,,,28.05,,,percent of total billed charges,,,,,,,,,28.05,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.99,,,percent of total billed charges,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,16.55,,,percent of total billed charges,,,548.68,,,per diem,,,28.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,28.05,,,percent of total billed charges,,,23.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.9,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.92,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,,,,,,,,,,,,,11.22,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,28.05,,,percent of total billed charges,,,28.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.24,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,21.04,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,19.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.03,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,16.53,,,percent of total billed charges,,
VECURONIUM BR 10 MG/10 ML INJ,2500018070,CDM,250,RC,J3490,HCPCS,4733593144,NDC,435,EAPG,,outpatient,facility,10,UN,28.05,28.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VENLAFAXINE HCL 25 MG TAB,2500018081,CDM,637,RC,5140745390,NDC,,,,,,inpatient,facility,25,UN,0.46,0.46,0.04,0.46,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,
VENLAFAXINE HCL 25 MG TAB,2500018081,CDM,637,RC,5140745390,NDC,,,,,,outpatient,facility,25,UN,0.46,0.46,0.04,548.68,,0.33,,,percent of total billed charges,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,0.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.17,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.46,,,fee schedule,,,0.46,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,0.27,,,percent of total billed charges,,,548.68,,,per diem,,,0.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.46,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,0.17,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.27,,,percent of total billed charges,,
VENLAFAXINE HCL 25 MG TAB,2500018081,CDM,637,RC,5140745390,NDC,999,EAPG,,,,outpatient,facility,25,UN,0.46,0.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VENLAFAXINE HCL 37.5 MG TAB,2500018082,CDM,637,RC,6808484401,NDC,,,,,,inpatient,facility,37.5,UN,6.6,6.6,0.53,6.6,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,6.6,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.89,,,percent of total billed charges,,
VENLAFAXINE HCL 37.5 MG TAB,2500018082,CDM,637,RC,6808484401,NDC,,,,,,outpatient,facility,37.5,UN,6.6,6.6,0.53,548.68,,4.68,,,percent of total billed charges,,,1.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.6,,,percent of total billed charges,,,4.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.42,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.6,,,fee schedule,,,6.6,,,percent of total billed charges,,,,,,,,,6.6,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.7,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,3.43,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,,,,,,,3.89,,,percent of total billed charges,,,548.68,,,per diem,,,6.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.6,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.45,,,percent of total billed charges,,,5.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,2.44,,,percent of total billed charges,,,2.44,,,percent of total billed charges,,,,,,,,,6.6,,,percent of total billed charges,,,6.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.53,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,,,,,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,6.14,,,percent of total billed charges,,,,,,,,,,,,,,,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,6.14,,,percent of total billed charges,,,4.95,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,6.6,,,percent of total billed charges,,,,,,,,,4.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.89,,,percent of total billed charges,,
VENLAFAXINE HCL 37.5 MG TAB,2500018082,CDM,637,RC,6808484401,NDC,999,EAPG,,,,outpatient,facility,37.5,UN,6.6,6.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VENLAFAXINE HCL SR 37.5 MG CAP,2500018086,CDM,637,RC,6586252790,NDC,,,,,,inpatient,facility,37.5,UN,13.73,13.73,1.1,13.73,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,,,,,,,13.73,,,percent of total billed charges,,,7.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.24,,,percent of total billed charges,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,11.67,,,percent of total billed charges,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,
VENLAFAXINE HCL SR 37.5 MG CAP,2500018086,CDM,637,RC,6586252790,NDC,,,,,,outpatient,facility,37.5,UN,13.73,13.73,1.1,548.68,,9.74,,,percent of total billed charges,,,3.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.73,,,percent of total billed charges,,,8.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.03,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.73,,,fee schedule,,,13.73,,,percent of total billed charges,,,,,,,,,13.73,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,,,,,,,,,,,,,,7.41,,,percent of total billed charges,,,7.14,,,percent of total billed charges,,,7.55,,,percent of total billed charges,,,,,,,,,8.1,,,percent of total billed charges,,,548.68,,,per diem,,,13.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.73,,,percent of total billed charges,,,11.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.29,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.26,,,percent of total billed charges,,,11.11,,,percent of total billed charges,,,,,,,,,,,,,,,5.49,,,percent of total billed charges,,,,,,,,,5.08,,,percent of total billed charges,,,5.08,,,percent of total billed charges,,,,,,,,,13.73,,,percent of total billed charges,,,13.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.1,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,,,,,,,,,,,,,13.73,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,,,,,,,12.77,,,percent of total billed charges,,,,,,,,,,,,,,,12.77,,,percent of total billed charges,,,12.77,,,percent of total billed charges,,,12.77,,,percent of total billed charges,,,10.3,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,13.73,,,percent of total billed charges,,,,,,,,,9.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.09,,,percent of total billed charges,,
VENLAFAXINE HCL SR 37.5 MG CAP,2500018086,CDM,637,RC,6586252790,NDC,999,EAPG,,,,outpatient,facility,37.5,UN,13.73,13.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VENLAFAXINE HCL SR 75 MG CAP,2500018087,CDM,637,RC,6586252890,NDC,,,,,,inpatient,facility,75,UN,15.41,15.41,1.23,15.41,,,,,,,,,,,,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.41,,,percent of total billed charges,,,,,,,,,15.41,,,percent of total billed charges,,,7.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.25,,,percent of total billed charges,,,,,,,,,,,,,,,15.41,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,15.41,,,percent of total billed charges,,,8.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.08,,,percent of total billed charges,,
VENLAFAXINE HCL SR 75 MG CAP,2500018087,CDM,637,RC,6586252890,NDC,,,,,,outpatient,facility,75,UN,15.41,15.41,1.23,548.68,,10.93,,,percent of total billed charges,,,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,15.41,,,percent of total billed charges,,,9.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.64,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,15.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,15.41,,,fee schedule,,,15.41,,,percent of total billed charges,,,,,,,,,15.41,,,percent of total billed charges,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.98,,,percent of total billed charges,,,,,,,,,,,,,,,8.32,,,percent of total billed charges,,,8.01,,,percent of total billed charges,,,8.48,,,percent of total billed charges,,,,,,,,,9.09,,,percent of total billed charges,,,548.68,,,per diem,,,15.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,15.41,,,percent of total billed charges,,,13.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.18,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.4,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,6.16,,,percent of total billed charges,,,,,,,,,5.7,,,percent of total billed charges,,,5.7,,,percent of total billed charges,,,,,,,,,15.41,,,percent of total billed charges,,,15.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.23,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,15.41,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,,,,,,,14.33,,,percent of total billed charges,,,,,,,,,,,,,,,14.33,,,percent of total billed charges,,,14.33,,,percent of total billed charges,,,14.33,,,percent of total billed charges,,,11.56,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,,,,,,,10.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.08,,,percent of total billed charges,,
VENLAFAXINE HCL SR 75 MG CAP,2500018087,CDM,637,RC,6586252890,NDC,999,EAPG,,,,outpatient,facility,75,UN,15.41,15.41,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VERAPAMIL 2.5 MG/ML 2 ML INJ,2500018101,CDM,250,RC,7012115855,NDC,,,,,,inpatient,facility,2,UN,120.22,120.22,9.62,120.22,,,,,,,,,,,,,,120.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.22,,,percent of total billed charges,,,,,,,,,120.22,,,percent of total billed charges,,,61.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.13,,,percent of total billed charges,,,,,,,,,,,,,,,120.22,,,percent of total billed charges,,,102.19,,,percent of total billed charges,,,,,,,,,,,,,,,120.22,,,percent of total billed charges,,,63.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,120.22,,,percent of total billed charges,,,,,,,,,,,,,,,9.62,,,percent of total billed charges,,,120.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,120.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.83,,,percent of total billed charges,,
VERAPAMIL 2.5 MG/ML 2 ML INJ,2500018101,CDM,250,RC,7012115855,NDC,,,,,,outpatient,facility,2,UN,120.22,120.22,9.62,548.68,,85.25,,,percent of total billed charges,,,29.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,120.22,,,percent of total billed charges,,,75.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,84.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,84.51,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,120.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,120.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,120.22,,,fee schedule,,,120.22,,,percent of total billed charges,,,,,,,,,120.22,,,percent of total billed charges,,,73.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,70.93,,,percent of total billed charges,,,548.68,,,per diem,,,120.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,120.22,,,percent of total billed charges,,,102.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.85,,,percent of total billed charges,,,120.22,,,percent of total billed charges,,,120.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.1,,,percent of total billed charges,,,97.28,,,percent of total billed charges,,,,,,,,,,,,,,,48.09,,,percent of total billed charges,,,,,,,,,48.09,,,percent of total billed charges,,,48.09,,,percent of total billed charges,,,,,,,,,120.22,,,percent of total billed charges,,,120.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,120.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.62,,,percent of total billed charges,,,120.22,,,percent of total billed charges,,,,,,,,,,,,,,,120.22,,,percent of total billed charges,,,120.22,,,percent of total billed charges,,,,,,,,,48.09,,,percent of total billed charges,,,,,,,,,,,,,,,48.09,,,percent of total billed charges,,,48.09,,,percent of total billed charges,,,48.09,,,percent of total billed charges,,,90.16,,,percent of total billed charges,,,120.22,,,percent of total billed charges,,,120.22,,,percent of total billed charges,,,120.22,,,percent of total billed charges,,,,,,,,,84.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.11,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,70.83,,,percent of total billed charges,,
VERAPAMIL 2.5 MG/ML 2 ML INJ,2500018101,CDM,250,RC,7012115855,NDC,999,EAPG,,,,outpatient,facility,2,UN,120.22,120.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VERAPAMIL HCL 80 MG TAB,2500018104,CDM,637,RC,2315502601,NDC,,,,,,inpatient,facility,80,UN,1.02,1.02,0.08,1.02,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,
VERAPAMIL HCL 80 MG TAB,2500018104,CDM,637,RC,2315502601,NDC,,,,,,outpatient,facility,80,UN,1.02,1.02,0.08,548.68,,0.72,,,percent of total billed charges,,,0.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.02,,,percent of total billed charges,,,0.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.37,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.02,,,fee schedule,,,1.02,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,0.6,,,percent of total billed charges,,,548.68,,,per diem,,,1.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.02,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,0.38,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.6,,,percent of total billed charges,,
VERAPAMIL HCL 80 MG TAB,2500018104,CDM,637,RC,2315502601,NDC,999,EAPG,,,,outpatient,facility,80,UN,1.02,1.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VERAPAMIL HCL 120 MG TAB,2500018105,CDM,637,RC,1054457030,NDC,,,,,,inpatient,facility,120,UN,2.01,2.01,0.16,2.01,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
VERAPAMIL HCL 120 MG TAB,2500018105,CDM,637,RC,1054457030,NDC,,,,,,outpatient,facility,120,UN,2.01,2.01,0.16,548.68,,1.43,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.01,,,percent of total billed charges,,,1.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.01,,,fee schedule,,,2.01,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,1.19,,,percent of total billed charges,,,548.68,,,per diem,,,2.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.01,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
VERAPAMIL HCL 120 MG TAB,2500018105,CDM,637,RC,1054457030,NDC,999,EAPG,,,,outpatient,facility,120,UN,2.01,2.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VERAPAMIL HCL 120 MG SR CAP,2500018110,CDM,637,RC,591288001,NDC,,,,,,inpatient,facility,120,UN,5.78,5.78,0.46,5.78,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,5.78,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,3.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.41,,,percent of total billed charges,,
VERAPAMIL HCL 120 MG SR CAP,2500018110,CDM,637,RC,591288001,NDC,,,,,,outpatient,facility,120,UN,5.78,5.78,0.46,548.68,,4.1,,,percent of total billed charges,,,1.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.78,,,percent of total billed charges,,,3.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.12,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.78,,,fee schedule,,,5.78,,,percent of total billed charges,,,,,,,,,5.78,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,3.01,,,percent of total billed charges,,,3.18,,,percent of total billed charges,,,,,,,,,3.41,,,percent of total billed charges,,,548.68,,,per diem,,,5.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.78,,,percent of total billed charges,,,4.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.07,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,2.14,,,percent of total billed charges,,,2.14,,,percent of total billed charges,,,,,,,,,5.78,,,percent of total billed charges,,,5.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,5.38,,,percent of total billed charges,,,,,,,,,,,,,,,5.38,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,4.33,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,4.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.41,,,percent of total billed charges,,
VERAPAMIL HCL 120 MG SR CAP,2500018110,CDM,637,RC,591288001,NDC,999,EAPG,,,,outpatient,facility,120,UN,5.78,5.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VERAPAMIL HCL 120 MG SR TAB,2500018111,CDM,637,RC,6846229201,NDC,,,,,,inpatient,facility,120,UN,3.53,3.53,0.28,3.53,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,3.53,,,percent of total billed charges,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,
VERAPAMIL HCL 120 MG SR TAB,2500018111,CDM,637,RC,6846229201,NDC,,,,,,outpatient,facility,120,UN,3.53,3.53,0.28,548.68,,2.5,,,percent of total billed charges,,,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.53,,,percent of total billed charges,,,2.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.53,,,fee schedule,,,3.53,,,percent of total billed charges,,,,,,,,,3.53,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,548.68,,,per diem,,,3.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.53,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,1.31,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,,,,,,,3.53,,,percent of total billed charges,,,3.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.28,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,3.28,,,percent of total billed charges,,,3.28,,,percent of total billed charges,,,3.28,,,percent of total billed charges,,,2.65,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.08,,,percent of total billed charges,,
VERAPAMIL HCL 120 MG SR TAB,2500018111,CDM,637,RC,6846229201,NDC,999,EAPG,,,,outpatient,facility,120,UN,3.53,3.53,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VERAPAMIL HCL 180 MG SR TAB,2500018113,CDM,637,RC,6846229301,NDC,,,,,,inpatient,facility,180,UN,4.75,4.75,0.38,4.75,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,4.75,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.85,,,percent of total billed charges,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,
VERAPAMIL HCL 180 MG SR TAB,2500018113,CDM,637,RC,6846229301,NDC,,,,,,outpatient,facility,180,UN,4.75,4.75,0.38,548.68,,3.37,,,percent of total billed charges,,,1.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.75,,,percent of total billed charges,,,2.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.75,,,fee schedule,,,4.75,,,percent of total billed charges,,,,,,,,,4.75,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,,,,,,,2.8,,,percent of total billed charges,,,548.68,,,per diem,,,4.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.75,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,3.84,,,percent of total billed charges,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,1.76,,,percent of total billed charges,,,1.76,,,percent of total billed charges,,,,,,,,,4.75,,,percent of total billed charges,,,4.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.38,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,4.42,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,4.75,,,percent of total billed charges,,,,,,,,,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.8,,,percent of total billed charges,,
VERAPAMIL HCL 180 MG SR TAB,2500018113,CDM,637,RC,6846229301,NDC,999,EAPG,,,,outpatient,facility,180,UN,4.75,4.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VERAPAMIL HCL 240 MG SR TAB,2500018114,CDM,637,RC,6846226001,NDC,,,,,,inpatient,facility,240,UN,5.41,5.41,0.43,5.41,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,5.41,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.25,,,percent of total billed charges,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.19,,,percent of total billed charges,,
VERAPAMIL HCL 240 MG SR TAB,2500018114,CDM,637,RC,6846226001,NDC,,,,,,outpatient,facility,240,UN,5.41,5.41,0.43,548.68,,3.84,,,percent of total billed charges,,,1.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.41,,,percent of total billed charges,,,3.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.98,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.41,,,fee schedule,,,5.41,,,percent of total billed charges,,,,,,,,,5.41,,,percent of total billed charges,,,3.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,,2.81,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,,,,,,,3.19,,,percent of total billed charges,,,548.68,,,per diem,,,5.41,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.41,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.65,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,,,,,,,,,,,,,2.16,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,5.41,,,percent of total billed charges,,,5.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.43,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,5.03,,,percent of total billed charges,,,5.03,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,5.41,,,percent of total billed charges,,,,,,,,,3.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.19,,,percent of total billed charges,,
VERAPAMIL HCL 240 MG SR TAB,2500018114,CDM,637,RC,6846226001,NDC,999,EAPG,,,,outpatient,facility,240,UN,5.41,5.41,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VIT B CMPLX/VITC/FA (NEPHROCAP,2500018170,CDM,637,RC,6954326010,NDC,,,,,,inpatient,facility,1,UN,2.21,2.21,0.18,2.21,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,
VIT B CMPLX/VITC/FA (NEPHROCAP,2500018170,CDM,637,RC,6954326010,NDC,,,,,,outpatient,facility,1,UN,2.21,2.21,0.18,548.68,,1.57,,,percent of total billed charges,,,0.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.21,,,percent of total billed charges,,,1.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.81,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.21,,,fee schedule,,,2.21,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,1.22,,,percent of total billed charges,,,,,,,,,1.3,,,percent of total billed charges,,,548.68,,,per diem,,,2.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.21,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.17,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,,,,,,,0.82,,,percent of total billed charges,,,0.82,,,percent of total billed charges,,,,,,,,,2.21,,,percent of total billed charges,,,2.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,2.06,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,2.21,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.3,,,percent of total billed charges,,
VIT B CMPLX/VITC/FA (NEPHROCAP,2500018170,CDM,637,RC,6954326010,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.21,2.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VITAMIN A 25000 IU CAP,2500018183,CDM,637,RC,5848702351,NDC,,,,,,inpatient,facility,25000,UN,0.53,0.53,0.04,0.53,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,0.53,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,
VITAMIN A 25000 IU CAP,2500018183,CDM,637,RC,5848702351,NDC,,,,,,outpatient,facility,25000,UN,0.53,0.53,0.04,548.68,,0.38,,,percent of total billed charges,,,0.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.53,,,percent of total billed charges,,,0.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.19,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.53,,,fee schedule,,,0.53,,,percent of total billed charges,,,,,,,,,0.53,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.31,,,percent of total billed charges,,,548.68,,,per diem,,,0.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.53,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,0.2,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,0.53,,,percent of total billed charges,,,0.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.31,,,percent of total billed charges,,
VITAMIN A 25000 IU CAP,2500018183,CDM,637,RC,5848702351,NDC,999,EAPG,,,,outpatient,facility,25000,UN,0.53,0.53,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VITAMIN B COMPLEX,2500018191,CDM,637,RC,5026885715,NDC,,,,,,inpatient,facility,1,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
VITAMIN B COMPLEX,2500018191,CDM,637,RC,5026885715,NDC,,,,,,outpatient,facility,1,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
VITAMIN B COMPLEX,2500018191,CDM,637,RC,5026885715,NDC,999,EAPG,,,,outpatient,facility,1,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VITAMIN B COMPLEX/VIT C TAB,2500018195,CDM,637,RC,536730001,NDC,,,,,,inpatient,facility,0.8,UN,0.47,0.47,0.04,0.47,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,0.47,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,
VITAMIN B COMPLEX/VIT C TAB,2500018195,CDM,637,RC,536730001,NDC,,,,,,outpatient,facility,0.8,UN,0.47,0.47,0.04,548.68,,0.33,,,percent of total billed charges,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.47,,,percent of total billed charges,,,0.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.17,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.47,,,fee schedule,,,0.47,,,percent of total billed charges,,,,,,,,,0.47,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,0.28,,,percent of total billed charges,,,548.68,,,per diem,,,0.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.47,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,,,,,,,0.19,,,percent of total billed charges,,,,,,,,,0.17,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,0.47,,,percent of total billed charges,,,0.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,,,,,,,0.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.28,,,percent of total billed charges,,
VITAMIN B COMPLEX/VIT C TAB,2500018195,CDM,637,RC,536730001,NDC,999,EAPG,,,,outpatient,facility,0.8,UN,0.47,0.47,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VITAMIN E 400 IU CAPSULE,2500018212,CDM,637,RC,7733395110,NDC,,,,,,inpatient,facility,400,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
VITAMIN E 400 IU CAPSULE,2500018212,CDM,637,RC,7733395110,NDC,,,,,,outpatient,facility,400,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
VITAMIN E 400 IU CAPSULE,2500018212,CDM,637,RC,7733395110,NDC,999,EAPG,,,,outpatient,facility,400,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WARFARIN SOD 1 MG TAB,2500018230,CDM,637,RC,832121101,NDC,,,,,,inpatient,facility,1,UN,2.01,2.01,0.16,2.01,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
WARFARIN SOD 1 MG TAB,2500018230,CDM,637,RC,832121101,NDC,,,,,,outpatient,facility,1,UN,2.01,2.01,0.16,548.68,,1.43,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.01,,,percent of total billed charges,,,1.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.01,,,fee schedule,,,2.01,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,1.05,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,1.19,,,percent of total billed charges,,,548.68,,,per diem,,,2.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.01,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.36,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2.01,,,percent of total billed charges,,,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,1.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.87,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
WARFARIN SOD 1 MG TAB,2500018230,CDM,637,RC,832121101,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.01,2.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WARFARIN SOD 10 MG TAB,2500018231,CDM,637,RC,93172001,NDC,,,,,,inpatient,facility,10,UN,3.37,3.37,0.27,3.37,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,3.37,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,
WARFARIN SOD 10 MG TAB,2500018231,CDM,637,RC,93172001,NDC,,,,,,outpatient,facility,10,UN,3.37,3.37,0.27,548.68,,2.39,,,percent of total billed charges,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.37,,,percent of total billed charges,,,2.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.37,,,fee schedule,,,3.37,,,percent of total billed charges,,,,,,,,,3.37,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,1.99,,,percent of total billed charges,,,548.68,,,per diem,,,3.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.37,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.79,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.27,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,3.37,,,percent of total billed charges,,,3.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.27,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,3.13,,,percent of total billed charges,,,2.53,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.99,,,percent of total billed charges,,
WARFARIN SOD 10 MG TAB,2500018231,CDM,637,RC,93172001,NDC,999,EAPG,,,,outpatient,facility,10,UN,3.37,3.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WARFARIN SOD 2 MG TAB,2500018232,CDM,637,RC,832121201,NDC,,,,,,inpatient,facility,2,UN,2.11,2.11,0.17,2.11,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,2.11,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,
WARFARIN SOD 2 MG TAB,2500018232,CDM,637,RC,832121201,NDC,,,,,,outpatient,facility,2,UN,2.11,2.11,0.17,548.68,,1.5,,,percent of total billed charges,,,0.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.11,,,percent of total billed charges,,,1.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.77,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.11,,,fee schedule,,,2.11,,,percent of total billed charges,,,,,,,,,2.11,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,1.24,,,percent of total billed charges,,,548.68,,,per diem,,,2.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.11,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,0.78,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,2.11,,,percent of total billed charges,,,2.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,1.96,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.24,,,percent of total billed charges,,
WARFARIN SOD 2 MG TAB,2500018232,CDM,637,RC,832121201,NDC,999,EAPG,,,,outpatient,facility,2,UN,2.11,2.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WARFARIN SOD 2.5 MG TAB,2500018233,CDM,637,RC,832121301,NDC,,,,,,inpatient,facility,2.5,UN,2.18,2.18,0.17,2.18,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,
WARFARIN SOD 2.5 MG TAB,2500018233,CDM,637,RC,832121301,NDC,,,,,,outpatient,facility,2.5,UN,2.18,2.18,0.17,548.68,,1.55,,,percent of total billed charges,,,0.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.18,,,percent of total billed charges,,,1.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.8,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.18,,,fee schedule,,,2.18,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,548.68,,,per diem,,,2.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.18,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,0.81,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.28,,,percent of total billed charges,,
WARFARIN SOD 2.5 MG TAB,2500018233,CDM,637,RC,832121301,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,2.18,2.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WARFARIN SOD 3 MG TAB,2500018234,CDM,637,RC,93171501,NDC,,,,,,inpatient,facility,3,UN,2.18,2.18,0.17,2.18,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.28,,,percent of total billed charges,,
WARFARIN SOD 3 MG TAB,2500018234,CDM,637,RC,93171501,NDC,,,,,,outpatient,facility,3,UN,2.18,2.18,0.17,548.68,,1.55,,,percent of total billed charges,,,0.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.18,,,percent of total billed charges,,,1.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.8,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.18,,,fee schedule,,,2.18,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.13,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,548.68,,,per diem,,,2.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.18,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,,,,,,,0.81,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,1.64,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.28,,,percent of total billed charges,,
WARFARIN SOD 3 MG TAB,2500018234,CDM,637,RC,93171501,NDC,999,EAPG,,,,outpatient,facility,3,UN,2.18,2.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WARFARIN SOD 5 MG TAB,2500018235,CDM,637,RC,832121601,NDC,,,,,,inpatient,facility,5,UN,2.28,2.28,0.18,2.28,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,2.28,,,percent of total billed charges,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,1.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,
WARFARIN SOD 5 MG TAB,2500018235,CDM,637,RC,832121601,NDC,,,,,,outpatient,facility,5,UN,2.28,2.28,0.18,548.68,,1.62,,,percent of total billed charges,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.28,,,percent of total billed charges,,,1.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.83,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.28,,,fee schedule,,,2.28,,,percent of total billed charges,,,,,,,,,2.28,,,percent of total billed charges,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,548.68,,,per diem,,,2.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.28,,,percent of total billed charges,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.21,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,1.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.91,,,percent of total billed charges,,,,,,,,,0.84,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,2.28,,,percent of total billed charges,,,2.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.18,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,,,,,,,1.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.34,,,percent of total billed charges,,
WARFARIN SOD 5 MG TAB,2500018235,CDM,637,RC,832121601,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.28,2.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WARFARIN SOD 7.5 MG TAB,2500018236,CDM,637,RC,832121801,NDC,,,,,,inpatient,facility,7.5,UN,3.04,3.04,0.24,3.04,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,3.04,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,2.58,,,percent of total billed charges,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.79,,,percent of total billed charges,,
WARFARIN SOD 7.5 MG TAB,2500018236,CDM,637,RC,832121801,NDC,,,,,,outpatient,facility,7.5,UN,3.04,3.04,0.24,548.68,,2.16,,,percent of total billed charges,,,0.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.04,,,percent of total billed charges,,,1.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.14,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.04,,,fee schedule,,,3.04,,,percent of total billed charges,,,,,,,,,3.04,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,1.79,,,percent of total billed charges,,,548.68,,,per diem,,,3.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.04,,,percent of total billed charges,,,2.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.05,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,3.04,,,percent of total billed charges,,,3.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,3.04,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,,,,,,,2.83,,,percent of total billed charges,,,,,,,,,,,,,,,2.83,,,percent of total billed charges,,,2.83,,,percent of total billed charges,,,2.83,,,percent of total billed charges,,,2.28,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,,,,,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.79,,,percent of total billed charges,,
WARFARIN SOD 7.5 MG TAB,2500018236,CDM,637,RC,832121801,NDC,999,EAPG,,,,outpatient,facility,7.5,UN,3.04,3.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WATER STERILE INJ 10 ML VIAL,2500018261,CDM,250,RC,6332318510,NDC,,,,,,inpatient,facility,10,UN,14.49,14.49,1.16,14.49,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,14.49,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.69,,,percent of total billed charges,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,12.32,,,percent of total billed charges,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,7.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.54,,,percent of total billed charges,,
WATER STERILE INJ 10 ML VIAL,2500018261,CDM,250,RC,6332318510,NDC,,,,,,outpatient,facility,10,UN,14.49,14.49,1.16,548.68,,10.27,,,percent of total billed charges,,,3.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.49,,,percent of total billed charges,,,9.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.49,,,fee schedule,,,14.49,,,percent of total billed charges,,,,,,,,,14.49,,,percent of total billed charges,,,8.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,8.55,,,percent of total billed charges,,,548.68,,,per diem,,,14.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.49,,,percent of total billed charges,,,12.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.7,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.77,,,percent of total billed charges,,,11.73,,,percent of total billed charges,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,,,,,,,5.8,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,,,,,,,14.49,,,percent of total billed charges,,,14.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.16,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,,,,,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,5.8,,,percent of total billed charges,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,10.87,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,14.49,,,percent of total billed charges,,,,,,,,,10.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.54,,,percent of total billed charges,,
WATER STERILE INJ 10 ML VIAL,2500018261,CDM,250,RC,6332318510,NDC,999,EAPG,,,,outpatient,facility,10,UN,14.49,14.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WATER STERILE INJ 100 ML VIAL,2500018262,CDM,250,RC,409488799,NDC,,,,,,inpatient,facility,100,UN,15.61,15.61,1.25,15.61,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,,,,,,,15.61,,,percent of total billed charges,,,7.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.37,,,percent of total billed charges,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,8.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.2,,,percent of total billed charges,,
WATER STERILE INJ 100 ML VIAL,2500018262,CDM,250,RC,409488799,NDC,,,,,,outpatient,facility,100,UN,15.61,15.61,1.25,548.68,,11.07,,,percent of total billed charges,,,3.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,15.61,,,percent of total billed charges,,,9.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,15.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,15.61,,,fee schedule,,,15.61,,,percent of total billed charges,,,,,,,,,15.61,,,percent of total billed charges,,,9.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,9.21,,,percent of total billed charges,,,548.68,,,per diem,,,15.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,15.61,,,percent of total billed charges,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.29,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.53,,,percent of total billed charges,,,12.63,,,percent of total billed charges,,,,,,,,,,,,,,,6.24,,,percent of total billed charges,,,,,,,,,6.24,,,percent of total billed charges,,,6.24,,,percent of total billed charges,,,,,,,,,15.61,,,percent of total billed charges,,,15.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.25,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,,,,,,,,,,,,,15.61,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,,,,,,,6.24,,,percent of total billed charges,,,,,,,,,,,,,,,6.24,,,percent of total billed charges,,,6.24,,,percent of total billed charges,,,6.24,,,percent of total billed charges,,,11.71,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,15.61,,,percent of total billed charges,,,,,,,,,10.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.2,,,percent of total billed charges,,
WATER STERILE INJ 100 ML VIAL,2500018262,CDM,250,RC,409488799,NDC,999,EAPG,,,,outpatient,facility,100,UN,15.61,15.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WATER STERILE INJ 1000 ML,2500018267,CDM,250,RC,264785000,NDC,,,,,,inpatient,facility,1000,UN,14.26,14.26,1.14,14.26,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,14.26,,,percent of total billed charges,,,7.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.56,,,percent of total billed charges,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,12.12,,,percent of total billed charges,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,7.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.4,,,percent of total billed charges,,
WATER STERILE INJ 1000 ML,2500018267,CDM,250,RC,264785000,NDC,,,,,,outpatient,facility,1000,UN,14.26,14.26,1.14,548.68,,10.11,,,percent of total billed charges,,,3.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.26,,,percent of total billed charges,,,8.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.26,,,fee schedule,,,14.26,,,percent of total billed charges,,,,,,,,,14.26,,,percent of total billed charges,,,8.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,8.41,,,percent of total billed charges,,,548.68,,,per diem,,,14.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.26,,,percent of total billed charges,,,12.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.57,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.62,,,percent of total billed charges,,,11.54,,,percent of total billed charges,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,,,,,,,5.7,,,percent of total billed charges,,,5.7,,,percent of total billed charges,,,,,,,,,14.26,,,percent of total billed charges,,,14.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.14,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,5.7,,,percent of total billed charges,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,5.7,,,percent of total billed charges,,,5.7,,,percent of total billed charges,,,10.7,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.4,,,percent of total billed charges,,
WATER STERILE INJ 1000 ML,2500018267,CDM,250,RC,264785000,NDC,999,EAPG,,,,outpatient,facility,1000,UN,14.26,14.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
WITCH HAZEL/GLYCERIN PADS  JAR,2500018291,CDM,637,RC,904682960,NDC,,,,,,inpatient,facility,100,UN,0.13,0.13,0.01,0.13,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,0.13,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,
WITCH HAZEL/GLYCERIN PADS  JAR,2500018291,CDM,637,RC,904682960,NDC,,,,,,outpatient,facility,100,UN,0.13,0.13,0.01,548.68,,0.09,,,percent of total billed charges,,,0.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,0.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.13,,,fee schedule,,,0.13,,,percent of total billed charges,,,,,,,,,0.13,,,percent of total billed charges,,,0.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,,,,,,,0.08,,,percent of total billed charges,,,548.68,,,per diem,,,0.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.13,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,,,,,,,0.05,,,percent of total billed charges,,,0.05,,,percent of total billed charges,,,,,,,,,0.13,,,percent of total billed charges,,,0.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,0.12,,,percent of total billed charges,,,0.1,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,0.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.08,,,percent of total billed charges,,
WITCH HAZEL/GLYCERIN PADS  JAR,2500018291,CDM,637,RC,904682960,NDC,999,EAPG,,,,outpatient,facility,100,UN,0.13,0.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZINC OXIDE 20  OINT 30 GM,2500018360,CDM,637,RC,536131628,NDC,,,,,,inpatient,facility,30,UN,4.94,4.94,0.4,4.94,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,,,,,,,4.94,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.96,,,percent of total billed charges,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,4.2,,,percent of total billed charges,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,2.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,
ZINC OXIDE 20  OINT 30 GM,2500018360,CDM,637,RC,536131628,NDC,,,,,,outpatient,facility,30,UN,4.94,4.94,0.4,548.68,,3.5,,,percent of total billed charges,,,1.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,4.94,,,percent of total billed charges,,,3.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.47,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.81,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4.94,,,fee schedule,,,4.94,,,percent of total billed charges,,,,,,,,,4.94,,,percent of total billed charges,,,3.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,2.57,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,,,,,,,2.91,,,percent of total billed charges,,,548.68,,,per diem,,,4.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4.94,,,percent of total billed charges,,,4.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,4.94,,,percent of total billed charges,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.33,,,percent of total billed charges,,,4,,,percent of total billed charges,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,,,,,,,1.83,,,percent of total billed charges,,,1.83,,,percent of total billed charges,,,,,,,,,4.94,,,percent of total billed charges,,,4.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.4,,,percent of total billed charges,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,4.94,,,percent of total billed charges,,,4.94,,,percent of total billed charges,,,,,,,,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,4.6,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,3.71,,,percent of total billed charges,,,4.94,,,percent of total billed charges,,,4.94,,,percent of total billed charges,,,4.94,,,percent of total billed charges,,,,,,,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.91,,,percent of total billed charges,,
ZINC OXIDE 20  OINT 30 GM,2500018360,CDM,637,RC,536131628,NDC,999,EAPG,,,,outpatient,facility,30,UN,4.94,4.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZINC OXIDE 40  OINT 120 GM,2500018364,CDM,637,RC,7430000071,NDC,,,,,,inpatient,facility,114,UN,19.4,19.4,1.55,19.4,,,,,,,,,,,,,,19.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.4,,,percent of total billed charges,,,,,,,,,19.4,,,percent of total billed charges,,,9.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.64,,,percent of total billed charges,,,,,,,,,,,,,,,19.4,,,percent of total billed charges,,,16.49,,,percent of total billed charges,,,,,,,,,,,,,,,19.4,,,percent of total billed charges,,,10.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,19.4,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,19.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.43,,,percent of total billed charges,,
ZINC OXIDE 40  OINT 120 GM,2500018364,CDM,637,RC,7430000071,NDC,,,,,,outpatient,facility,114,UN,19.4,19.4,1.55,548.68,,13.76,,,percent of total billed charges,,,4.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,19.4,,,percent of total billed charges,,,12.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,13.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,13.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,19.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,19.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,19.4,,,fee schedule,,,19.4,,,percent of total billed charges,,,,,,,,,19.4,,,percent of total billed charges,,,11.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.82,,,percent of total billed charges,,,,,,,,,,,,,,,10.48,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,10.67,,,percent of total billed charges,,,,,,,,,11.45,,,percent of total billed charges,,,548.68,,,per diem,,,19.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,19.4,,,percent of total billed charges,,,16.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.3,,,percent of total billed charges,,,19.4,,,percent of total billed charges,,,19.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.09,,,percent of total billed charges,,,15.7,,,percent of total billed charges,,,,,,,,,,,,,,,7.76,,,percent of total billed charges,,,,,,,,,7.18,,,percent of total billed charges,,,7.18,,,percent of total billed charges,,,,,,,,,19.4,,,percent of total billed charges,,,19.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.55,,,percent of total billed charges,,,19.4,,,percent of total billed charges,,,,,,,,,,,,,,,19.4,,,percent of total billed charges,,,19.4,,,percent of total billed charges,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,14.55,,,percent of total billed charges,,,19.4,,,percent of total billed charges,,,19.4,,,percent of total billed charges,,,19.4,,,percent of total billed charges,,,,,,,,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.43,,,percent of total billed charges,,
ZINC OXIDE 40  OINT 120 GM,2500018364,CDM,637,RC,7430000071,NDC,999,EAPG,,,,outpatient,facility,114,UN,19.4,19.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZINC SULF 220 MG CAP,2500018382,CDM,637,RC,7733398310,NDC,,,,,,inpatient,facility,220,UN,1.67,1.67,0.13,1.67,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,1.67,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,
ZINC SULF 220 MG CAP,2500018382,CDM,637,RC,7733398310,NDC,,,,,,outpatient,facility,220,UN,1.67,1.67,0.13,548.68,,1.18,,,percent of total billed charges,,,0.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.67,,,percent of total billed charges,,,1.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.61,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.67,,,fee schedule,,,1.67,,,percent of total billed charges,,,,,,,,,1.67,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.9,,,percent of total billed charges,,,0.87,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,548.68,,,per diem,,,1.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.67,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,0.62,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,,,,,,,1.67,,,percent of total billed charges,,,1.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,1.67,,,percent of total billed charges,,,,,,,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.98,,,percent of total billed charges,,
ZINC SULF 220 MG CAP,2500018382,CDM,637,RC,7733398310,NDC,999,EAPG,,,,outpatient,facility,220,UN,1.67,1.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZIPRASIDONE 20 MG CAP,2500018390,CDM,637,RC,5511125660,NDC,,,,,,inpatient,facility,20,UN,29.24,29.24,2.34,29.24,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,,,,,,,29.24,,,percent of total billed charges,,,14.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.54,,,percent of total billed charges,,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,24.85,,,percent of total billed charges,,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,15.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.23,,,percent of total billed charges,,
ZIPRASIDONE 20 MG CAP,2500018390,CDM,637,RC,5511125660,NDC,,,,,,outpatient,facility,20,UN,29.24,29.24,2.34,548.68,,20.73,,,percent of total billed charges,,,7.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,29.24,,,percent of total billed charges,,,18.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,20.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,20.56,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.7,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,29.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,29.24,,,fee schedule,,,29.24,,,percent of total billed charges,,,,,,,,,29.24,,,percent of total billed charges,,,17.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.83,,,percent of total billed charges,,,,,,,,,,,,,,,15.79,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,16.08,,,percent of total billed charges,,,,,,,,,17.25,,,percent of total billed charges,,,548.68,,,per diem,,,29.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,29.24,,,percent of total billed charges,,,24.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.53,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.73,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,,,,,,,,,,,,,11.7,,,percent of total billed charges,,,,,,,,,10.82,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,,,,,,,29.24,,,percent of total billed charges,,,29.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.34,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,,,,,,,,,,,,,29.24,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,,,,,,,27.2,,,percent of total billed charges,,,,,,,,,,,,,,,27.2,,,percent of total billed charges,,,27.2,,,percent of total billed charges,,,27.2,,,percent of total billed charges,,,21.93,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,29.24,,,percent of total billed charges,,,,,,,,,20.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.62,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.23,,,percent of total billed charges,,
ZIPRASIDONE 20 MG CAP,2500018390,CDM,637,RC,5511125660,NDC,999,EAPG,,,,outpatient,facility,20,UN,29.24,29.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZIPRASIDONE 40 MG CAP,2500018391,CDM,637,RC,5511125760,NDC,,,,,,inpatient,facility,40,UN,29.23,29.23,2.34,29.23,,,,,,,,,,,,,,29.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.23,,,percent of total billed charges,,,,,,,,,29.23,,,percent of total billed charges,,,14.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.54,,,percent of total billed charges,,,,,,,,,,,,,,,29.23,,,percent of total billed charges,,,24.85,,,percent of total billed charges,,,,,,,,,,,,,,,29.23,,,percent of total billed charges,,,15.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,29.23,,,percent of total billed charges,,,,,,,,,,,,,,,2.34,,,percent of total billed charges,,,29.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.22,,,percent of total billed charges,,
ZIPRASIDONE 40 MG CAP,2500018391,CDM,637,RC,5511125760,NDC,,,,,,outpatient,facility,40,UN,29.23,29.23,2.34,548.68,,20.73,,,percent of total billed charges,,,7.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,29.23,,,percent of total billed charges,,,18.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,20.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,20.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,29.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.7,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,29.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,29.23,,,fee schedule,,,29.23,,,percent of total billed charges,,,,,,,,,29.23,,,percent of total billed charges,,,17.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.83,,,percent of total billed charges,,,,,,,,,,,,,,,15.78,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,16.08,,,percent of total billed charges,,,,,,,,,17.25,,,percent of total billed charges,,,548.68,,,per diem,,,29.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,29.23,,,percent of total billed charges,,,24.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.52,,,percent of total billed charges,,,29.23,,,percent of total billed charges,,,29.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.72,,,percent of total billed charges,,,23.65,,,percent of total billed charges,,,,,,,,,,,,,,,11.69,,,percent of total billed charges,,,,,,,,,10.82,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,,,,,,,29.23,,,percent of total billed charges,,,29.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.34,,,percent of total billed charges,,,29.23,,,percent of total billed charges,,,,,,,,,,,,,,,29.23,,,percent of total billed charges,,,29.23,,,percent of total billed charges,,,,,,,,,27.19,,,percent of total billed charges,,,,,,,,,,,,,,,27.19,,,percent of total billed charges,,,27.19,,,percent of total billed charges,,,27.19,,,percent of total billed charges,,,21.92,,,percent of total billed charges,,,29.23,,,percent of total billed charges,,,29.23,,,percent of total billed charges,,,29.23,,,percent of total billed charges,,,,,,,,,20.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.62,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.22,,,percent of total billed charges,,
ZIPRASIDONE 40 MG CAP,2500018391,CDM,637,RC,5511125760,NDC,999,EAPG,,,,outpatient,facility,40,UN,29.23,29.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZIPRASIDONE 20 MG/ML INJ,2500018395,CDM,636,RC,J3486,HCPCS,7226616010,NDC,,,,inpatient,facility,20,UN,108.21,108.21,8.66,108.21,,,,,,,,,,,,,,108.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.21,,,percent of total billed charges,,,,,,,,,108.21,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.93,,,percent of total billed charges,,,,,,,,,,,,,,,108.21,,,percent of total billed charges,,,91.98,,,percent of total billed charges,,,,,,,,,,,,,,,108.21,,,percent of total billed charges,,,57.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,108.21,,,percent of total billed charges,,,,,,,,,,,,,,,8.66,,,percent of total billed charges,,,108.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,108.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.76,,,percent of total billed charges,,
ZIPRASIDONE 20 MG/ML INJ,2500018395,CDM,636,RC,J3486,HCPCS,7226616010,NDC,,,,outpatient,facility,20,UN,108.21,108.21,8.38,548.68,,76.73,,,percent of total billed charges,,,26.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,108.21,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,108.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,39.6,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,108.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,108.21,,,fee schedule,,,108.21,,,percent of total billed charges,,,,,,,,,108.21,,,percent of total billed charges,,,66.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,63.84,,,percent of total billed charges,,,548.68,,,per diem,,,108.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,108.21,,,percent of total billed charges,,,91.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.47,,,percent of total billed charges,,,108.21,,,percent of total billed charges,,,108.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73,,,percent of total billed charges,,,87.56,,,percent of total billed charges,,,,,,,,,,,,,,,43.28,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,108.21,,,percent of total billed charges,,,108.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,108.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.66,,,percent of total billed charges,,,108.21,,,percent of total billed charges,,,,,,,,,,,,,,,108.21,,,percent of total billed charges,,,108.21,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,8.38,,,fee schedule,,,108.21,,,percent of total billed charges,,,108.21,,,percent of total billed charges,,,108.21,,,percent of total billed charges,,,,,,,,,75.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,63.76,,,percent of total billed charges,,
ZIPRASIDONE 20 MG/ML INJ,2500018395,CDM,636,RC,J3486,HCPCS,7226616010,NDC,435,EAPG,,outpatient,facility,20,UN,108.21,108.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZOLPIDEM TART 5 MG TAB,2500018401,CDM,637,RC,904608261,NDC,,,,,,inpatient,facility,5,UN,0.29,0.29,0.02,0.29,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,
ZOLPIDEM TART 5 MG TAB,2500018401,CDM,637,RC,904608261,NDC,,,,,,outpatient,facility,5,UN,0.29,0.29,0.02,548.68,,0.21,,,percent of total billed charges,,,0.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.29,,,percent of total billed charges,,,0.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.29,,,fee schedule,,,0.29,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,0.16,,,percent of total billed charges,,,,,,,,,0.17,,,percent of total billed charges,,,548.68,,,per diem,,,0.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.29,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,0.12,,,percent of total billed charges,,,,,,,,,0.11,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.02,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,0.29,,,percent of total billed charges,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.17,,,percent of total billed charges,,
ZOLPIDEM TART 5 MG TAB,2500018401,CDM,637,RC,904608261,NDC,999,EAPG,,,,outpatient,facility,5,UN,0.29,0.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE 0.25  30 ML INJ,2500018410,CDM,250,RC,5515016830,NDC,,,,,,inpatient,facility,30,UN,10.56,10.56,0.84,10.56,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,10.56,,,percent of total billed charges,,,5.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.22,,,percent of total billed charges,,
BUPIVACAINE 0.25  30 ML INJ,2500018410,CDM,250,RC,5515016830,NDC,,,,,,outpatient,facility,30,UN,10.56,10.56,0.84,548.68,,7.49,,,percent of total billed charges,,,2.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.56,,,percent of total billed charges,,,6.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.86,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.56,,,fee schedule,,,10.56,,,percent of total billed charges,,,,,,,,,10.56,,,percent of total billed charges,,,6.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,6.23,,,percent of total billed charges,,,548.68,,,per diem,,,10.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.56,,,percent of total billed charges,,,8.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.12,,,percent of total billed charges,,,8.55,,,percent of total billed charges,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,,,,,,,4.22,,,percent of total billed charges,,,4.22,,,percent of total billed charges,,,,,,,,,10.56,,,percent of total billed charges,,,10.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.84,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,4.22,,,percent of total billed charges,,,4.22,,,percent of total billed charges,,,7.92,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,,,,,,,7.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.22,,,percent of total billed charges,,
BUPIVACAINE 0.25  30 ML INJ,2500018410,CDM,250,RC,5515016830,NDC,999,EAPG,,,,outpatient,facility,30,UN,10.56,10.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE 0.5  30 ML INJ,2500018411,CDM,250,RC,J3490,HCPCS,409116202,NDC,,,,inpatient,facility,30,UN,7.39,7.39,0.59,7.39,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,,,,,,,7.39,,,percent of total billed charges,,,3.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.43,,,percent of total billed charges,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,6.28,,,percent of total billed charges,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.35,,,percent of total billed charges,,
BUPIVACAINE 0.5  30 ML INJ,2500018411,CDM,250,RC,J3490,HCPCS,409116202,NDC,,,,outpatient,facility,30,UN,7.39,7.39,0.59,548.68,,5.24,,,percent of total billed charges,,,1.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.39,,,percent of total billed charges,,,4.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.7,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,7.39,,,fee schedule,,,7.39,,,percent of total billed charges,,,,,,,,,7.39,,,percent of total billed charges,,,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,percent of total billed charges,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,4.36,,,percent of total billed charges,,,548.68,,,per diem,,,7.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.39,,,percent of total billed charges,,,6.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.99,,,percent of total billed charges,,,5.98,,,percent of total billed charges,,,,,,,,,,,,,,,2.96,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,7.39,,,percent of total billed charges,,,7.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.59,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,5.54,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,,,,,,,5.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.35,,,percent of total billed charges,,
BUPIVACAINE 0.5  30 ML INJ,2500018411,CDM,250,RC,J3490,HCPCS,409116202,NDC,435,EAPG,,outpatient,facility,30,UN,7.39,7.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE 0.5  10 ML INJ,2500018414,CDM,250,RC,J3490,HCPCS,5515016910,NDC,,,,inpatient,facility,10,UN,11.88,11.88,0.95,11.88,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,11.88,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,6.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7,,,percent of total billed charges,,
BUPIVACAINE 0.5  10 ML INJ,2500018414,CDM,250,RC,J3490,HCPCS,5515016910,NDC,,,,outpatient,facility,10,UN,11.88,11.88,0.95,548.68,,8.42,,,percent of total billed charges,,,2.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,11.88,,,percent of total billed charges,,,7.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.35,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,11.88,,,fee schedule,,,11.88,,,percent of total billed charges,,,,,,,,,11.88,,,percent of total billed charges,,,7.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.46,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,7.01,,,percent of total billed charges,,,548.68,,,per diem,,,11.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11.88,,,percent of total billed charges,,,10.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.31,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.01,,,percent of total billed charges,,,9.61,,,percent of total billed charges,,,,,,,,,,,,,,,4.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11.88,,,percent of total billed charges,,,11.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.95,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,8.91,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,,,,,,,8.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7,,,percent of total billed charges,,
BUPIVACAINE 0.5  10 ML INJ,2500018414,CDM,250,RC,J3490,HCPCS,5515016910,NDC,435,EAPG,,outpatient,facility,10,UN,11.88,11.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE 0.75  10 ML INJ,2500018415,CDM,250,RC,J3490,HCPCS,5515017110,NDC,,,,inpatient,facility,10,UN,11.81,11.81,0.94,11.81,,,,,,,,,,,,,,11.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.81,,,percent of total billed charges,,,,,,,,,11.81,,,percent of total billed charges,,,6.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.09,,,percent of total billed charges,,,,,,,,,,,,,,,11.81,,,percent of total billed charges,,,10.04,,,percent of total billed charges,,,,,,,,,,,,,,,11.81,,,percent of total billed charges,,,6.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11.81,,,percent of total billed charges,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,11.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,
BUPIVACAINE 0.75  10 ML INJ,2500018415,CDM,250,RC,J3490,HCPCS,5515017110,NDC,,,,outpatient,facility,10,UN,11.81,11.81,0.94,548.68,,8.37,,,percent of total billed charges,,,2.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,11.81,,,percent of total billed charges,,,7.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.32,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,11.81,,,fee schedule,,,11.81,,,percent of total billed charges,,,,,,,,,11.81,,,percent of total billed charges,,,7.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.41,,,percent of total billed charges,,,,,,,,,,,,,,,11.81,,,percent of total billed charges,,,11.81,,,percent of total billed charges,,,11.81,,,percent of total billed charges,,,,,,,,,6.97,,,percent of total billed charges,,,548.68,,,per diem,,,11.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11.81,,,percent of total billed charges,,,10.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.97,,,percent of total billed charges,,,9.56,,,percent of total billed charges,,,,,,,,,,,,,,,4.72,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,11.81,,,percent of total billed charges,,,11.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.94,,,percent of total billed charges,,,11.81,,,percent of total billed charges,,,,,,,,,,,,,,,11.81,,,percent of total billed charges,,,11.81,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,8.86,,,percent of total billed charges,,,11.81,,,percent of total billed charges,,,11.81,,,percent of total billed charges,,,11.81,,,percent of total billed charges,,,,,,,,,8.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.96,,,percent of total billed charges,,
BUPIVACAINE 0.75  10 ML INJ,2500018415,CDM,250,RC,J3490,HCPCS,5515017110,NDC,435,EAPG,,outpatient,facility,10,UN,11.81,11.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE/EPI 0.25  30ML INJ,2500018420,CDM,250,RC,J3490,HCPCS,6332346837,NDC,,,,inpatient,facility,30,UN,35.01,35.01,2.8,35.01,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,,,,,,,35.01,,,percent of total billed charges,,,17.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.01,,,percent of total billed charges,,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,29.76,,,percent of total billed charges,,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,18.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,,35.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.63,,,percent of total billed charges,,
BUPIVACAINE/EPI 0.25  30ML INJ,2500018420,CDM,250,RC,J3490,HCPCS,6332346837,NDC,,,,outpatient,facility,30,UN,35.01,35.01,1.2,548.68,,24.83,,,percent of total billed charges,,,8.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,35.01,,,percent of total billed charges,,,21.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,24.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,24.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.81,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,35.01,,,fee schedule,,,35.01,,,percent of total billed charges,,,,,,,,,35.01,,,percent of total billed charges,,,21.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.94,,,percent of total billed charges,,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,35.01,,,percent of total billed charges,,,35.01,,,percent of total billed charges,,,,,,,,,20.66,,,percent of total billed charges,,,548.68,,,per diem,,,35.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,35.01,,,percent of total billed charges,,,29.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.59,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.62,,,percent of total billed charges,,,28.33,,,percent of total billed charges,,,,,,,,,,,,,,,14,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,35.01,,,percent of total billed charges,,,35.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.8,,,percent of total billed charges,,,35.01,,,percent of total billed charges,,,,,,,,,,,,,,,35.01,,,percent of total billed charges,,,35.01,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,26.26,,,percent of total billed charges,,,35.01,,,percent of total billed charges,,,35.01,,,percent of total billed charges,,,35.01,,,percent of total billed charges,,,,,,,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,20.63,,,percent of total billed charges,,
BUPIVACAINE/EPI 0.25  30ML INJ,2500018420,CDM,250,RC,J3490,HCPCS,6332346837,NDC,435,EAPG,,outpatient,facility,30,UN,35.01,35.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE/EPI 0.5  10 ML INJ,2500018422,CDM,250,RC,J3490,HCPCS,6332346217,NDC,,,,inpatient,facility,10,UN,22.7,22.7,1.82,22.7,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,,,,,,,22.7,,,percent of total billed charges,,,11.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.62,,,percent of total billed charges,,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,19.29,,,percent of total billed charges,,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,12.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,,,,,,,,,,,,,1.82,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.37,,,percent of total billed charges,,
BUPIVACAINE/EPI 0.5  10 ML INJ,2500018422,CDM,250,RC,J3490,HCPCS,6332346217,NDC,,,,outpatient,facility,10,UN,22.7,22.7,1.2,548.68,,16.1,,,percent of total billed charges,,,5.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,22.7,,,percent of total billed charges,,,14.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,15.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,15.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.31,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,22.7,,,fee schedule,,,22.7,,,percent of total billed charges,,,,,,,,,22.7,,,percent of total billed charges,,,13.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.17,,,percent of total billed charges,,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,,,,,,,13.39,,,percent of total billed charges,,,548.68,,,per diem,,,22.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,22.7,,,percent of total billed charges,,,19.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.06,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,18.37,,,percent of total billed charges,,,,,,,,,,,,,,,9.08,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,22.7,,,percent of total billed charges,,,22.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.82,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,,,,,,,,,,,,,22.7,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,17.02,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,,,,,,,15.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.37,,,percent of total billed charges,,
BUPIVACAINE/EPI 0.5  10 ML INJ,2500018422,CDM,250,RC,J3490,HCPCS,6332346217,NDC,435,EAPG,,outpatient,facility,10,UN,22.7,22.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE/EPI 0.5  30 ML INJ,2500018423,CDM,250,RC,J3490,HCPCS,6332346237,NDC,,,,inpatient,facility,30,UN,34.62,34.62,2.77,34.62,,,,,,,,,,,,,,34.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.62,,,percent of total billed charges,,,,,,,,,34.62,,,percent of total billed charges,,,17.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,34.62,,,percent of total billed charges,,,29.43,,,percent of total billed charges,,,,,,,,,,,,,,,34.62,,,percent of total billed charges,,,18.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,34.62,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,34.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.4,,,percent of total billed charges,,
BUPIVACAINE/EPI 0.5  30 ML INJ,2500018423,CDM,250,RC,J3490,HCPCS,6332346237,NDC,,,,outpatient,facility,30,UN,34.62,34.62,1.2,548.68,,24.55,,,percent of total billed charges,,,8.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,34.62,,,percent of total billed charges,,,21.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,24.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,24.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,34.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.67,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,34.62,,,fee schedule,,,34.62,,,percent of total billed charges,,,,,,,,,34.62,,,percent of total billed charges,,,21.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.67,,,percent of total billed charges,,,,,,,,,,,,,,,34.62,,,percent of total billed charges,,,34.62,,,percent of total billed charges,,,34.62,,,percent of total billed charges,,,,,,,,,20.43,,,percent of total billed charges,,,548.68,,,per diem,,,34.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,34.62,,,percent of total billed charges,,,29.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.39,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.35,,,percent of total billed charges,,,28.01,,,percent of total billed charges,,,,,,,,,,,,,,,13.85,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,34.62,,,percent of total billed charges,,,34.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,34.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.77,,,percent of total billed charges,,,34.62,,,percent of total billed charges,,,,,,,,,,,,,,,34.62,,,percent of total billed charges,,,34.62,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,25.96,,,percent of total billed charges,,,34.62,,,percent of total billed charges,,,34.62,,,percent of total billed charges,,,34.62,,,percent of total billed charges,,,,,,,,,24.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,20.4,,,percent of total billed charges,,
BUPIVACAINE/EPI 0.5  30 ML INJ,2500018423,CDM,250,RC,J3490,HCPCS,6332346237,NDC,435,EAPG,,outpatient,facility,30,UN,34.62,34.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INDOCYANINE GREEN 25 MG INJ,2500018430,CDM,250,RC,1723842406,NDC,,,,,,inpatient,facility,25,UN,840.48,840.48,67.24,840.48,,,,,,,,,,,,,,840.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,840.48,,,percent of total billed charges,,,,,,,,,840.48,,,percent of total billed charges,,,429.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,715.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,504.29,,,percent of total billed charges,,,,,,,,,,,,,,,840.48,,,percent of total billed charges,,,714.41,,,percent of total billed charges,,,,,,,,,,,,,,,840.48,,,percent of total billed charges,,,446.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,336.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,840.48,,,percent of total billed charges,,,,,,,,,,,,,,,67.24,,,percent of total billed charges,,,840.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,840.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,495.21,,,percent of total billed charges,,
INDOCYANINE GREEN 25 MG INJ,2500018430,CDM,250,RC,1723842406,NDC,,,,,,outpatient,facility,25,UN,840.48,840.48,67.24,840.48,,595.98,,,percent of total billed charges,,,205.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,840.48,,,percent of total billed charges,,,526.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,590.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,590.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,840.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,307.62,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,840.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,840.48,,,fee schedule,,,840.48,,,percent of total billed charges,,,,,,,,,840.48,,,percent of total billed charges,,,515.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,598.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,495.88,,,percent of total billed charges,,,548.68,,,per diem,,,840.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,840.48,,,percent of total billed charges,,,714.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,446.38,,,percent of total billed charges,,,840.48,,,percent of total billed charges,,,840.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,566.99,,,percent of total billed charges,,,680.12,,,percent of total billed charges,,,,,,,,,,,,,,,336.19,,,percent of total billed charges,,,,,,,,,336.19,,,percent of total billed charges,,,336.19,,,percent of total billed charges,,,,,,,,,840.48,,,percent of total billed charges,,,840.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,840.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,67.24,,,percent of total billed charges,,,840.48,,,percent of total billed charges,,,,,,,,,,,,,,,840.48,,,percent of total billed charges,,,840.48,,,percent of total billed charges,,,,,,,,,336.19,,,percent of total billed charges,,,,,,,,,,,,,,,336.19,,,percent of total billed charges,,,336.19,,,percent of total billed charges,,,336.19,,,percent of total billed charges,,,630.36,,,percent of total billed charges,,,840.48,,,percent of total billed charges,,,840.48,,,percent of total billed charges,,,840.48,,,percent of total billed charges,,,,,,,,,589.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,495.21,,,percent of total billed charges,,
INDOCYANINE GREEN 25 MG INJ,2500018430,CDM,250,RC,1723842406,NDC,999,EAPG,,,,outpatient,facility,25,UN,840.48,840.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETYLCYSTEINE INH 800 MG/4 ML,2500018470,CDM,637,RC,J7608,HCPCS,6332369404,NDC,,,,inpatient,facility,4,ML,52.7,52.7,4.22,52.7,,,,,,,,,,,,,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.7,,,percent of total billed charges,,,,,,,,,52.7,,,percent of total billed charges,,,26.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.62,,,percent of total billed charges,,,,,,,,,,,,,,,52.7,,,percent of total billed charges,,,44.8,,,percent of total billed charges,,,,,,,,,,,,,,,52.7,,,percent of total billed charges,,,27.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,
ACETYLCYSTEINE INH 800 MG/4 ML,2500018470,CDM,637,RC,J7608,HCPCS,6332369404,NDC,,,,outpatient,facility,4,ML,52.7,52.7,2.41,548.68,,37.37,,,percent of total billed charges,,,12.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,52.7,,,percent of total billed charges,,,11.82,,,fee schedule,,,11.19,,,fee schedule,,,,,,,,,11.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,19.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.41,,,fee schedule,,,7.77,,,fee schedule,,,52.7,,,percent of total billed charges,,,,,,,,,52.7,,,percent of total billed charges,,,32.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.55,,,percent of total billed charges,,,,,,,,,,,,,,,6.83,,,fee schedule,,,6.83,,,fee schedule,,,6.83,,,fee schedule,,,,,,,,,31.09,,,percent of total billed charges,,,548.68,,,per diem,,,52.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,52.7,,,percent of total billed charges,,,44.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.99,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.55,,,percent of total billed charges,,,42.64,,,percent of total billed charges,,,,,,,,,,,,,,,21.08,,,percent of total billed charges,,,,,,,,,18.16,,,fee schedule,,,13.07,,,fee schedule,,,,,,,,,52.7,,,percent of total billed charges,,,52.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,52.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.22,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,52.7,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,,,,,,,7.76,,,fee schedule,,,,,,,,,,,,,,,6.73,,,fee schedule,,,8.97,,,fee schedule,,,5.04,,,fee schedule,,,9.45,,,fee schedule,,,52.7,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,,,,,,,36.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,31.05,,,percent of total billed charges,,
ACETYLCYSTEINE INH 800 MG/4 ML,2500018470,CDM,637,RC,J7608,HCPCS,6332369404,NDC,496,EAPG,,outpatient,facility,4,ML,52.7,52.7,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETYLCYSTEINE 6 GM/30 ML IV,2500018475,CDM,636,RC,J0132,HCPCS,6332396330,NDC,,,,inpatient,facility,30,UN,363,363,29.04,363,,,,,,,,,,,,,,363,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363,,,percent of total billed charges,,,,,,,,,363,,,percent of total billed charges,,,185.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,309.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.8,,,percent of total billed charges,,,,,,,,,,,,,,,363,,,percent of total billed charges,,,308.55,,,percent of total billed charges,,,,,,,,,,,,,,,363,,,percent of total billed charges,,,192.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,363,,,percent of total billed charges,,,,,,,,,,,,,,,29.04,,,percent of total billed charges,,,363,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,363,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.88,,,percent of total billed charges,,
ACETYLCYSTEINE 6 GM/30 ML IV,2500018475,CDM,636,RC,J0132,HCPCS,6332396330,NDC,,,,outpatient,facility,30,UN,363,363,0.59,548.68,,257.4,,,percent of total billed charges,,,88.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,363,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,363,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,132.86,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,363,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,363,,,fee schedule,,,363,,,percent of total billed charges,,,,,,,,,363,,,percent of total billed charges,,,222.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,fee schedule,,,0.7,,,fee schedule,,,0.7,,,fee schedule,,,,,,,,,214.17,,,percent of total billed charges,,,548.68,,,per diem,,,363,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,363,,,percent of total billed charges,,,308.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,192.79,,,percent of total billed charges,,,363,,,percent of total billed charges,,,363,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,244.88,,,percent of total billed charges,,,293.74,,,percent of total billed charges,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,363,,,percent of total billed charges,,,363,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,363,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.04,,,percent of total billed charges,,,363,,,percent of total billed charges,,,,,,,,,,,,,,,363,,,percent of total billed charges,,,363,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,363,,,percent of total billed charges,,,363,,,percent of total billed charges,,,363,,,percent of total billed charges,,,,,,,,,254.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,213.88,,,percent of total billed charges,,
ACETYLCYSTEINE 6 GM/30 ML IV,2500018475,CDM,636,RC,J0132,HCPCS,6332396330,NDC,999,EAPG,,outpatient,facility,30,UN,363,363,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LETROZOLE 2.5 MG TAB,2500018500,CDM,637,RC,5199175933,NDC,,,,,,inpatient,facility,2.5,UN,59.76,59.76,4.78,59.76,,,,,,,,,,,,,,59.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.76,,,percent of total billed charges,,,,,,,,,59.76,,,percent of total billed charges,,,30.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.86,,,percent of total billed charges,,,,,,,,,,,,,,,59.76,,,percent of total billed charges,,,50.8,,,percent of total billed charges,,,,,,,,,,,,,,,59.76,,,percent of total billed charges,,,31.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,59.76,,,percent of total billed charges,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,59.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.21,,,percent of total billed charges,,
LETROZOLE 2.5 MG TAB,2500018500,CDM,637,RC,5199175933,NDC,,,,,,outpatient,facility,2.5,UN,59.76,59.76,4.78,548.68,,42.38,,,percent of total billed charges,,,14.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,59.76,,,percent of total billed charges,,,37.45,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,42.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,42.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,59.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,21.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,59.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,59.76,,,fee schedule,,,59.76,,,percent of total billed charges,,,,,,,,,59.76,,,percent of total billed charges,,,36.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.58,,,percent of total billed charges,,,,,,,,,,,,,,,32.27,,,percent of total billed charges,,,31.08,,,percent of total billed charges,,,32.87,,,percent of total billed charges,,,,,,,,,35.26,,,percent of total billed charges,,,548.68,,,per diem,,,59.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,59.76,,,percent of total billed charges,,,50.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.74,,,percent of total billed charges,,,59.76,,,percent of total billed charges,,,59.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.31,,,percent of total billed charges,,,48.36,,,percent of total billed charges,,,,,,,,,,,,,,,23.9,,,percent of total billed charges,,,,,,,,,22.11,,,percent of total billed charges,,,22.11,,,percent of total billed charges,,,,,,,,,59.76,,,percent of total billed charges,,,59.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,59.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.78,,,percent of total billed charges,,,59.76,,,percent of total billed charges,,,,,,,,,,,,,,,59.76,,,percent of total billed charges,,,59.76,,,percent of total billed charges,,,,,,,,,55.59,,,percent of total billed charges,,,,,,,,,,,,,,,55.59,,,percent of total billed charges,,,55.59,,,percent of total billed charges,,,55.59,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,59.76,,,percent of total billed charges,,,59.76,,,percent of total billed charges,,,59.76,,,percent of total billed charges,,,,,,,,,41.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,35.21,,,percent of total billed charges,,
LETROZOLE 2.5 MG TAB,2500018500,CDM,637,RC,5199175933,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,59.76,59.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZOLEDRONIC ACID 4 MG/ZOMETA,2500018515,CDM,636,RC,J3489,HCPCS,1672924231,NDC,,,,inpatient,facility,5,UN,1007.78,1007.78,80.62,1007.78,,,,,,,,,,,,,,1007.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1007.78,,,percent of total billed charges,,,,,,,,,1007.78,,,percent of total billed charges,,,514.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,858.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,604.67,,,percent of total billed charges,,,,,,,,,,,,,,,1007.78,,,percent of total billed charges,,,856.61,,,percent of total billed charges,,,,,,,,,,,,,,,1007.78,,,percent of total billed charges,,,535.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1007.78,,,percent of total billed charges,,,,,,,,,,,,,,,80.62,,,percent of total billed charges,,,1007.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1007.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,593.78,,,percent of total billed charges,,
ZOLEDRONIC ACID 4 MG/ZOMETA,2500018515,CDM,636,RC,J3489,HCPCS,1672924231,NDC,,,,outpatient,facility,5,UN,1007.78,1007.78,5.94,1007.78,,714.62,,,percent of total billed charges,,,245.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1007.78,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,1007.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,368.85,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,120.18,,,fee schedule,,,1007.78,,,fee schedule,,,1007.78,,,percent of total billed charges,,,,,,,,,1007.78,,,percent of total billed charges,,,617.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,718.04,,,percent of total billed charges,,,,,,,,,,,,,,,7.21,,,fee schedule,,,7.21,,,fee schedule,,,7.21,,,fee schedule,,,,,,,,,594.59,,,percent of total billed charges,,,548.68,,,per diem,,,1007.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1007.78,,,percent of total billed charges,,,856.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,535.23,,,percent of total billed charges,,,1007.78,,,percent of total billed charges,,,1007.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,679.85,,,percent of total billed charges,,,815.5,,,percent of total billed charges,,,,,,,,,,,,,,,403.11,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1007.78,,,percent of total billed charges,,,1007.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1007.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,80.62,,,percent of total billed charges,,,1007.78,,,percent of total billed charges,,,,,,,,,,,,,,,1007.78,,,percent of total billed charges,,,1007.78,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,5.94,,,fee schedule,,,1007.78,,,percent of total billed charges,,,1007.78,,,percent of total billed charges,,,1007.78,,,percent of total billed charges,,,,,,,,,706.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,503.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,593.78,,,percent of total billed charges,,
ZOLEDRONIC ACID 4 MG/ZOMETA,2500018515,CDM,636,RC,J3489,HCPCS,1672924231,NDC,435,EAPG,,outpatient,facility,5,UN,1007.78,1007.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZONISAMIDE 100 MG CAP,2500018520,CDM,637,RC,5026881615,NDC,,,,,,inpatient,facility,100,UN,5.67,5.67,0.45,5.67,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,,,,,,,5.67,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.34,,,percent of total billed charges,,
ZONISAMIDE 100 MG CAP,2500018520,CDM,637,RC,5026881615,NDC,,,,,,outpatient,facility,100,UN,5.67,5.67,0.45,548.68,,4.02,,,percent of total billed charges,,,1.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.67,,,percent of total billed charges,,,3.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.67,,,fee schedule,,,5.67,,,percent of total billed charges,,,,,,,,,5.67,,,percent of total billed charges,,,3.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,3.06,,,percent of total billed charges,,,2.95,,,percent of total billed charges,,,3.12,,,percent of total billed charges,,,,,,,,,3.35,,,percent of total billed charges,,,548.68,,,per diem,,,5.67,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.67,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.82,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,,,,,,,,,,,,,2.27,,,percent of total billed charges,,,,,,,,,2.1,,,percent of total billed charges,,,2.1,,,percent of total billed charges,,,,,,,,,5.67,,,percent of total billed charges,,,5.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.45,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,5.67,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,,,,,,,5.27,,,percent of total billed charges,,,,,,,,,,,,,,,5.27,,,percent of total billed charges,,,5.27,,,percent of total billed charges,,,5.27,,,percent of total billed charges,,,4.25,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,,,,,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.34,,,percent of total billed charges,,
ZONISAMIDE 100 MG CAP,2500018520,CDM,637,RC,5026881615,NDC,999,EAPG,,,,outpatient,facility,100,UN,5.67,5.67,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZONISAMIDE 25 MG,2500018523,CDM,637,RC,6846212801,NDC,,,,,,inpatient,facility,25,UN,1.81,1.81,0.14,1.81,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,1.81,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,
ZONISAMIDE 25 MG,2500018523,CDM,637,RC,6846212801,NDC,,,,,,outpatient,facility,25,UN,1.81,1.81,0.14,548.68,,1.28,,,percent of total billed charges,,,0.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.81,,,percent of total billed charges,,,1.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.66,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.81,,,fee schedule,,,1.81,,,percent of total billed charges,,,,,,,,,1.81,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,0.94,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,1.07,,,percent of total billed charges,,,548.68,,,per diem,,,1.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.81,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,1.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,0.67,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,1.81,,,percent of total billed charges,,,1.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.14,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,1.81,,,percent of total billed charges,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.07,,,percent of total billed charges,,
ZONISAMIDE 25 MG,2500018523,CDM,637,RC,6846212801,NDC,999,EAPG,,,,outpatient,facility,25,UN,1.81,1.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MODAFINIL 100 MG TAB,2500018530,CDM,637,RC,6233238530,NDC,,,,,,inpatient,facility,100,UN,72.83,72.83,5.83,72.83,,,,,,,,,,,,,,72.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.83,,,percent of total billed charges,,,,,,,,,72.83,,,percent of total billed charges,,,37.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.7,,,percent of total billed charges,,,,,,,,,,,,,,,72.83,,,percent of total billed charges,,,61.91,,,percent of total billed charges,,,,,,,,,,,,,,,72.83,,,percent of total billed charges,,,38.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,72.83,,,percent of total billed charges,,,,,,,,,,,,,,,5.83,,,percent of total billed charges,,,72.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.91,,,percent of total billed charges,,
MODAFINIL 100 MG TAB,2500018530,CDM,637,RC,6233238530,NDC,,,,,,outpatient,facility,100,UN,72.83,72.83,5.83,548.68,,51.64,,,percent of total billed charges,,,17.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,72.83,,,percent of total billed charges,,,45.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,51.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,51.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,72.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,26.66,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,72.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,72.83,,,fee schedule,,,72.83,,,percent of total billed charges,,,,,,,,,72.83,,,percent of total billed charges,,,44.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.89,,,percent of total billed charges,,,,,,,,,,,,,,,39.33,,,percent of total billed charges,,,37.87,,,percent of total billed charges,,,40.06,,,percent of total billed charges,,,,,,,,,42.97,,,percent of total billed charges,,,548.68,,,per diem,,,72.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,72.83,,,percent of total billed charges,,,61.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.68,,,percent of total billed charges,,,72.83,,,percent of total billed charges,,,72.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.13,,,percent of total billed charges,,,58.93,,,percent of total billed charges,,,,,,,,,,,,,,,29.13,,,percent of total billed charges,,,,,,,,,26.95,,,percent of total billed charges,,,26.95,,,percent of total billed charges,,,,,,,,,72.83,,,percent of total billed charges,,,72.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,72.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.83,,,percent of total billed charges,,,72.83,,,percent of total billed charges,,,,,,,,,,,,,,,72.83,,,percent of total billed charges,,,72.83,,,percent of total billed charges,,,,,,,,,67.75,,,percent of total billed charges,,,,,,,,,,,,,,,67.75,,,percent of total billed charges,,,67.75,,,percent of total billed charges,,,67.75,,,percent of total billed charges,,,54.62,,,percent of total billed charges,,,72.83,,,percent of total billed charges,,,72.83,,,percent of total billed charges,,,72.83,,,percent of total billed charges,,,,,,,,,51.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,42.91,,,percent of total billed charges,,
MODAFINIL 100 MG TAB,2500018530,CDM,637,RC,6233238530,NDC,999,EAPG,,,,outpatient,facility,100,UN,72.83,72.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NATEGLINIDE 60 MG TAB,2500018545,CDM,637,RC,6808445821,NDC,,,,,,inpatient,facility,60,UN,6.43,6.43,0.51,6.43,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,,,,,,,,6.43,,,percent of total billed charges,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.86,,,percent of total billed charges,,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,,3.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.79,,,percent of total billed charges,,
NATEGLINIDE 60 MG TAB,2500018545,CDM,637,RC,6808445821,NDC,,,,,,outpatient,facility,60,UN,6.43,6.43,0.51,548.68,,4.56,,,percent of total billed charges,,,1.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.43,,,percent of total billed charges,,,4.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.35,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.43,,,fee schedule,,,6.43,,,percent of total billed charges,,,,,,,,,6.43,,,percent of total billed charges,,,3.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,3.47,,,percent of total billed charges,,,3.34,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,,,,,,,3.79,,,percent of total billed charges,,,548.68,,,per diem,,,6.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.43,,,percent of total billed charges,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.41,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.34,,,percent of total billed charges,,,5.2,,,percent of total billed charges,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,2.38,,,percent of total billed charges,,,2.38,,,percent of total billed charges,,,,,,,,,6.43,,,percent of total billed charges,,,6.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.51,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,5.98,,,percent of total billed charges,,,,,,,,,,,,,,,5.98,,,percent of total billed charges,,,5.98,,,percent of total billed charges,,,5.98,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,4.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.79,,,percent of total billed charges,,
NATEGLINIDE 60 MG TAB,2500018545,CDM,637,RC,6808445821,NDC,999,EAPG,,,,outpatient,facility,60,UN,6.43,6.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TRANEXAMIC ACID 650 MG TAB,2500018575,CDM,637,RC,6991830130,NDC,,,,,,inpatient,facility,650,UN,17.19,17.19,1.38,17.19,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,,,,,,,17.19,,,percent of total billed charges,,,8.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.31,,,percent of total billed charges,,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,14.61,,,percent of total billed charges,,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,9.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.13,,,percent of total billed charges,,
TRANEXAMIC ACID 650 MG TAB,2500018575,CDM,637,RC,6991830130,NDC,,,,,,outpatient,facility,650,UN,17.19,17.19,1.38,548.68,,12.19,,,percent of total billed charges,,,4.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,17.19,,,percent of total billed charges,,,10.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,12.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,12.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,17.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,17.19,,,fee schedule,,,17.19,,,percent of total billed charges,,,,,,,,,17.19,,,percent of total billed charges,,,10.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.25,,,percent of total billed charges,,,,,,,,,,,,,,,9.28,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,9.45,,,percent of total billed charges,,,,,,,,,10.14,,,percent of total billed charges,,,548.68,,,per diem,,,17.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,17.19,,,percent of total billed charges,,,14.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.13,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.6,,,percent of total billed charges,,,13.91,,,percent of total billed charges,,,,,,,,,,,,,,,6.88,,,percent of total billed charges,,,,,,,,,6.36,,,percent of total billed charges,,,6.36,,,percent of total billed charges,,,,,,,,,17.19,,,percent of total billed charges,,,17.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.38,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,,,,,,,15.99,,,percent of total billed charges,,,,,,,,,,,,,,,15.99,,,percent of total billed charges,,,15.99,,,percent of total billed charges,,,15.99,,,percent of total billed charges,,,12.89,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,17.19,,,percent of total billed charges,,,,,,,,,12.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.13,,,percent of total billed charges,,
TRANEXAMIC ACID 650 MG TAB,2500018575,CDM,637,RC,6991830130,NDC,999,EAPG,,,,outpatient,facility,650,UN,17.19,17.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FULVESTRANT 50 MG/ML 5ML INJ,2500018624,CDM,636,RC,J9395,HCPCS,310772010,NDC,,,,inpatient,facility,5,GR,3168,3168,253.44,3168,,,,,,,,,,,,,,3168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3168,,,percent of total billed charges,,,,,,,,,3168,,,percent of total billed charges,,,1617.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2698.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1900.8,,,percent of total billed charges,,,,,,,,,,,,,,,3168,,,percent of total billed charges,,,2692.8,,,percent of total billed charges,,,,,,,,,,,,,,,3168,,,percent of total billed charges,,,1682.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1267.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3168,,,percent of total billed charges,,,,,,,,,,,,,,,253.44,,,percent of total billed charges,,,3168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1866.59,,,percent of total billed charges,,
FULVESTRANT 50 MG/ML 5ML INJ,2500018624,CDM,636,RC,J9395,HCPCS,310772010,NDC,,,,outpatient,facility,5,GR,3168,3168,7.54,3168,,8.17,,,fee schedule,,,,,,,,,3168,,,percent of total billed charges,,,11.33,,,fee schedule,,,10.72,,,fee schedule,,,,,,,,,10.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,97.41,,,fee schedule,,,3168,,,fee schedule,,,3168,,,percent of total billed charges,,,,,,,,,3168,,,percent of total billed charges,,,1941.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2257.2,,,percent of total billed charges,,,,,,,,,,,,,,,8.45,,,fee schedule,,,8.45,,,fee schedule,,,8.45,,,fee schedule,,,,,,,,,1869.12,,,percent of total billed charges,,,548.68,,,per diem,,,3168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3168,,,percent of total billed charges,,,2692.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1682.52,,,percent of total billed charges,,,3168,,,percent of total billed charges,,,3168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2137.13,,,percent of total billed charges,,,2563.55,,,percent of total billed charges,,,,,,,,,,,,,,,1267.2,,,percent of total billed charges,,,,,,,,,27.15,,,fee schedule,,,19.54,,,fee schedule,,,,,,,,,3168,,,percent of total billed charges,,,,,,,,,,,,,,,253.44,,,percent of total billed charges,,,3168,,,percent of total billed charges,,,,,,,,,,,,,,,3168,,,percent of total billed charges,,,3168,,,percent of total billed charges,,,,,,,,,11.6,,,fee schedule,,,,,,,,,,,,,,,10.06,,,fee schedule,,,13.41,,,fee schedule,,,7.54,,,fee schedule,,,9.05,,,fee schedule,,,3168,,,percent of total billed charges,,,3168,,,percent of total billed charges,,,3168,,,percent of total billed charges,,,,,,,,,2221.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1584,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1866.59,,,percent of total billed charges,,
FULVESTRANT 50 MG/ML 5ML INJ,2500018624,CDM,636,RC,J9395,HCPCS,310772010,NDC,9120,APC,,outpatient,facility,5,GR,3168,3168,6.39,1159.49,,,,,,,,6.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.73,,,fee schedule,,,,,,,,,1159.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,6.66,,,fee schedule,,,,,,,,,,,,,,,6.99,,,fee schedule,,,6.99,,,fee schedule,,,,,,,,,6.66,,,fee schedule,,,6.66,,,fee schedule,,,6.99,,,fee schedule,,,,,,,,,,,,,,,9.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,6.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.39,,,fee schedule,,,7.13,,,fee schedule,,,6.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.66,,,fee schedule,,,6.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,6.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,6.66,,,fee schedule,,,,,,,,,8.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,6.66,,,fee schedule,,,6.66,,,fee schedule,,,,,,,,,,,,,,,6.66,,,fee schedule,,,,,,,,,6.66,,,fee schedule,,,6.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.66,,,fee schedule,,,,,,,,,,,,,,,6.93,,,fee schedule,,,6.66,,,fee schedule,,,,,,,,,6.66,,,fee schedule,,,,,,,,,6.66,,,fee schedule,,,6.99,,,fee schedule,,,,,,,,
FULVESTRANT 50 MG/ML 5ML INJ,2500018624,CDM,636,RC,J9395,HCPCS,310772010,NDC,432,EAPG,,outpatient,facility,5,GR,3168,3168,148.29,223.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.92,,,fee schedule,,,148.29,,,fee schedule,,,199.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.29,,,fee schedule,,,148.29,,,fee schedule,,,148.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,148.29,,,fee schedule,,,,,,,,,,,,,,,148.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 2 /EPI 1 200000 20ML,2500018640,CDM,250,RC,J2004,HCPCS,6332348927,NDC,,,,inpatient,facility,20,UN,68.01,68.01,5.44,68.01,,,,,,,,,,,,,,68.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.01,,,percent of total billed charges,,,,,,,,,68.01,,,percent of total billed charges,,,34.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.81,,,percent of total billed charges,,,,,,,,,,,,,,,68.01,,,percent of total billed charges,,,57.81,,,percent of total billed charges,,,,,,,,,,,,,,,68.01,,,percent of total billed charges,,,36.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,68.01,,,percent of total billed charges,,,,,,,,,,,,,,,5.44,,,percent of total billed charges,,,68.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.07,,,percent of total billed charges,,
LIDOCAINE 2 /EPI 1 200000 20ML,2500018640,CDM,250,RC,J2004,HCPCS,6332348927,NDC,,,,outpatient,facility,20,UN,68.01,68.01,5.44,548.68,,48.23,,,percent of total billed charges,,,16.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,68.01,,,percent of total billed charges,,,42.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,47.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,47.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,68.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,24.89,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,68.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,68.01,,,fee schedule,,,68.01,,,percent of total billed charges,,,,,,,,,68.01,,,percent of total billed charges,,,41.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,40.13,,,percent of total billed charges,,,548.68,,,per diem,,,68.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,68.01,,,percent of total billed charges,,,57.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.12,,,percent of total billed charges,,,68.01,,,percent of total billed charges,,,68.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.88,,,percent of total billed charges,,,55.03,,,percent of total billed charges,,,,,,,,,,,,,,,27.2,,,percent of total billed charges,,,,,,,,,25.16,,,percent of total billed charges,,,25.16,,,percent of total billed charges,,,,,,,,,68.01,,,percent of total billed charges,,,68.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,68.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.44,,,percent of total billed charges,,,68.01,,,percent of total billed charges,,,,,,,,,,,,,,,68.01,,,percent of total billed charges,,,68.01,,,percent of total billed charges,,,,,,,,,63.26,,,percent of total billed charges,,,,,,,,,,,,,,,63.26,,,percent of total billed charges,,,63.26,,,percent of total billed charges,,,63.26,,,percent of total billed charges,,,51.01,,,percent of total billed charges,,,68.01,,,percent of total billed charges,,,68.01,,,percent of total billed charges,,,68.01,,,percent of total billed charges,,,,,,,,,47.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,40.07,,,percent of total billed charges,,
LIDOCAINE 2 /EPI 1 200000 20ML,2500018640,CDM,250,RC,J2004,HCPCS,6332348927,NDC,999,EAPG,,outpatient,facility,20,UN,68.01,68.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 2 /EPI 1 100000 20ML,2500018641,CDM,250,RC,J2004,HCPCS,6332348327,NDC,,,,inpatient,facility,20,UN,16.43,16.43,1.31,16.43,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,,,,,,,16.43,,,percent of total billed charges,,,8.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.86,,,percent of total billed charges,,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,13.97,,,percent of total billed charges,,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,8.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.31,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.68,,,percent of total billed charges,,
LIDOCAINE 2 /EPI 1 100000 20ML,2500018641,CDM,250,RC,J2004,HCPCS,6332348327,NDC,,,,outpatient,facility,20,UN,16.43,16.43,1.31,548.68,,11.65,,,percent of total billed charges,,,4.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,16.43,,,percent of total billed charges,,,10.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,11.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,11.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,16.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,16.43,,,fee schedule,,,16.43,,,percent of total billed charges,,,,,,,,,16.43,,,percent of total billed charges,,,10.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,9.69,,,percent of total billed charges,,,548.68,,,per diem,,,16.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,16.43,,,percent of total billed charges,,,13.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.73,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.08,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,6.57,,,percent of total billed charges,,,,,,,,,6.08,,,percent of total billed charges,,,6.08,,,percent of total billed charges,,,,,,,,,16.43,,,percent of total billed charges,,,16.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.31,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,,,,,,,,,,,,,16.43,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,,,,,,,15.28,,,percent of total billed charges,,,,,,,,,,,,,,,15.28,,,percent of total billed charges,,,15.28,,,percent of total billed charges,,,15.28,,,percent of total billed charges,,,12.32,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,16.43,,,percent of total billed charges,,,,,,,,,11.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.68,,,percent of total billed charges,,
LIDOCAINE 2 /EPI 1 100000 20ML,2500018641,CDM,250,RC,J2004,HCPCS,6332348327,NDC,999,EAPG,,outpatient,facility,20,UN,16.43,16.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 1 /EPI 1 200000 30ML,2500018643,CDM,250,RC,J2004,HCPCS,6332348737,NDC,,,,inpatient,facility,30,UN,44.52,44.52,3.56,44.52,,,,,,,,,,,,,,44.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.52,,,percent of total billed charges,,,,,,,,,44.52,,,percent of total billed charges,,,22.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.71,,,percent of total billed charges,,,,,,,,,,,,,,,44.52,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,,,,,,,,,,,,,44.52,,,percent of total billed charges,,,23.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,44.52,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,44.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,44.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.23,,,percent of total billed charges,,
LIDOCAINE 1 /EPI 1 200000 30ML,2500018643,CDM,250,RC,J2004,HCPCS,6332348737,NDC,,,,outpatient,facility,30,UN,44.52,44.52,3.56,548.68,,31.57,,,percent of total billed charges,,,10.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,44.52,,,percent of total billed charges,,,27.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,31.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,31.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,44.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,16.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,44.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,44.52,,,fee schedule,,,44.52,,,percent of total billed charges,,,,,,,,,44.52,,,percent of total billed charges,,,27.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,26.27,,,percent of total billed charges,,,548.68,,,per diem,,,44.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,44.52,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.64,,,percent of total billed charges,,,44.52,,,percent of total billed charges,,,44.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.03,,,percent of total billed charges,,,36.03,,,percent of total billed charges,,,,,,,,,,,,,,,17.81,,,percent of total billed charges,,,,,,,,,16.47,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,,,,,,,44.52,,,percent of total billed charges,,,44.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,44.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.56,,,percent of total billed charges,,,44.52,,,percent of total billed charges,,,,,,,,,,,,,,,44.52,,,percent of total billed charges,,,44.52,,,percent of total billed charges,,,,,,,,,41.41,,,percent of total billed charges,,,,,,,,,,,,,,,41.41,,,percent of total billed charges,,,41.41,,,percent of total billed charges,,,41.41,,,percent of total billed charges,,,33.39,,,percent of total billed charges,,,44.52,,,percent of total billed charges,,,44.52,,,percent of total billed charges,,,44.52,,,percent of total billed charges,,,,,,,,,31.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.26,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,26.23,,,percent of total billed charges,,
LIDOCAINE 1 /EPI 1 200000 30ML,2500018643,CDM,250,RC,J2004,HCPCS,6332348737,NDC,999,EAPG,,outpatient,facility,30,UN,44.52,44.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 1 /EPI 1 100000 20ML,2500018644,CDM,250,RC,J2004,HCPCS,6332348227,NDC,,,,inpatient,facility,20,UN,16.2,16.2,1.3,16.2,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,,,,,,,16.2,,,percent of total billed charges,,,8.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.72,,,percent of total billed charges,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,8.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.55,,,percent of total billed charges,,
LIDOCAINE 1 /EPI 1 100000 20ML,2500018644,CDM,250,RC,J2004,HCPCS,6332348227,NDC,,,,outpatient,facility,20,UN,16.2,16.2,1.3,548.68,,11.49,,,percent of total billed charges,,,3.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,16.2,,,percent of total billed charges,,,10.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,11.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,11.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.93,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,16.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,16.2,,,fee schedule,,,16.2,,,percent of total billed charges,,,,,,,,,16.2,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,9.56,,,percent of total billed charges,,,548.68,,,per diem,,,16.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,16.2,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.6,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.93,,,percent of total billed charges,,,13.11,,,percent of total billed charges,,,,,,,,,,,,,,,6.48,,,percent of total billed charges,,,,,,,,,5.99,,,percent of total billed charges,,,5.99,,,percent of total billed charges,,,,,,,,,16.2,,,percent of total billed charges,,,16.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.3,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,,,,,,,15.07,,,percent of total billed charges,,,,,,,,,,,,,,,15.07,,,percent of total billed charges,,,15.07,,,percent of total billed charges,,,15.07,,,percent of total billed charges,,,12.15,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,,,,,,,11.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.55,,,percent of total billed charges,,
LIDOCAINE 1 /EPI 1 100000 20ML,2500018644,CDM,250,RC,J2004,HCPCS,6332348227,NDC,999,EAPG,,outpatient,facility,20,UN,16.2,16.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 0.5 EPI 1 200000 50M,2500018648,CDM,250,RC,J2004,HCPCS,409317701,NDC,,,,inpatient,facility,50,UN,12.74,12.74,1.02,12.74,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,,,,,,,12.74,,,percent of total billed charges,,,6.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.64,,,percent of total billed charges,,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,10.83,,,percent of total billed charges,,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,6.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.51,,,percent of total billed charges,,
LIDOCAINE 0.5 EPI 1 200000 50M,2500018648,CDM,250,RC,J2004,HCPCS,409317701,NDC,,,,outpatient,facility,50,UN,12.74,12.74,1.02,548.68,,9.03,,,percent of total billed charges,,,3.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,12.74,,,percent of total billed charges,,,7.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.66,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,12.74,,,fee schedule,,,12.74,,,percent of total billed charges,,,,,,,,,12.74,,,percent of total billed charges,,,7.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.52,,,percent of total billed charges,,,548.68,,,per diem,,,12.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12.74,,,percent of total billed charges,,,10.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.77,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.59,,,percent of total billed charges,,,10.31,,,percent of total billed charges,,,,,,,,,,,,,,,5.1,,,percent of total billed charges,,,,,,,,,4.71,,,percent of total billed charges,,,4.71,,,percent of total billed charges,,,,,,,,,12.74,,,percent of total billed charges,,,12.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.02,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,,,,,,,,,,,,,12.74,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,,,,,,,11.85,,,percent of total billed charges,,,,,,,,,,,,,,,11.85,,,percent of total billed charges,,,11.85,,,percent of total billed charges,,,11.85,,,percent of total billed charges,,,9.55,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,,,,,,,8.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.37,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.51,,,percent of total billed charges,,
LIDOCAINE 0.5 EPI 1 200000 50M,2500018648,CDM,250,RC,J2004,HCPCS,409317701,NDC,999,EAPG,,outpatient,facility,50,UN,12.74,12.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 1 /EPI 1 100000 30ML,2500018649,CDM,250,RC,J2004,HCPCS,409317802,NDC,,,,inpatient,facility,30,UN,18.71,18.71,1.5,18.71,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,,,,,,,18.71,,,percent of total billed charges,,,9.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.23,,,percent of total billed charges,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,15.9,,,percent of total billed charges,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,9.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.02,,,percent of total billed charges,,
LIDOCAINE 1 /EPI 1 100000 30ML,2500018649,CDM,250,RC,J2004,HCPCS,409317802,NDC,,,,outpatient,facility,30,UN,18.71,18.71,1.5,548.68,,13.27,,,percent of total billed charges,,,4.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,18.71,,,percent of total billed charges,,,11.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,13.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,13.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.85,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,18.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,18.71,,,fee schedule,,,18.71,,,percent of total billed charges,,,,,,,,,18.71,,,percent of total billed charges,,,11.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,11.04,,,percent of total billed charges,,,548.68,,,per diem,,,18.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,18.71,,,percent of total billed charges,,,15.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.94,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.62,,,percent of total billed charges,,,15.14,,,percent of total billed charges,,,,,,,,,,,,,,,7.48,,,percent of total billed charges,,,,,,,,,6.92,,,percent of total billed charges,,,6.92,,,percent of total billed charges,,,,,,,,,18.71,,,percent of total billed charges,,,18.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.5,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,14.03,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,,,,,,,13.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.02,,,percent of total billed charges,,
LIDOCAINE 1 /EPI 1 100000 30ML,2500018649,CDM,250,RC,J2004,HCPCS,409317802,NDC,999,EAPG,,outpatient,facility,30,UN,18.71,18.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE SULF PF 5 MG/10 ML,2500018652,CDM,636,RC,J2274,HCPCS,641602010,NDC,,,,inpatient,facility,10,UN,95.57,95.57,7.65,95.57,,,,,,,,,,,,,,95.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.57,,,percent of total billed charges,,,,,,,,,95.57,,,percent of total billed charges,,,48.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.34,,,percent of total billed charges,,,,,,,,,,,,,,,95.57,,,percent of total billed charges,,,81.23,,,percent of total billed charges,,,,,,,,,,,,,,,95.57,,,percent of total billed charges,,,50.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,95.57,,,percent of total billed charges,,,,,,,,,,,,,,,7.65,,,percent of total billed charges,,,95.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.31,,,percent of total billed charges,,
MORPHINE SULF PF 5 MG/10 ML,2500018652,CDM,636,RC,J2274,HCPCS,641602010,NDC,,,,outpatient,facility,10,UN,95.57,95.57,7.65,548.68,,67.77,,,percent of total billed charges,,,23.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,95.57,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,95.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,34.98,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,95.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,95.57,,,fee schedule,,,95.57,,,percent of total billed charges,,,,,,,,,95.57,,,percent of total billed charges,,,58.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,56.39,,,percent of total billed charges,,,548.68,,,per diem,,,95.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,95.57,,,percent of total billed charges,,,81.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.76,,,percent of total billed charges,,,95.57,,,percent of total billed charges,,,95.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.47,,,percent of total billed charges,,,77.34,,,percent of total billed charges,,,,,,,,,,,,,,,38.23,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,95.57,,,percent of total billed charges,,,95.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,95.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.65,,,percent of total billed charges,,,95.57,,,percent of total billed charges,,,,,,,,,,,,,,,95.57,,,percent of total billed charges,,,95.57,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,10.88,,,fee schedule,,,95.57,,,percent of total billed charges,,,95.57,,,percent of total billed charges,,,95.57,,,percent of total billed charges,,,,,,,,,67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,56.31,,,percent of total billed charges,,
MORPHINE SULF PF 5 MG/10 ML,2500018652,CDM,636,RC,J2274,HCPCS,641602010,NDC,435,EAPG,,outpatient,facility,10,UN,95.57,95.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NALOXONE HCL 0.4 MG/ML AMP,2500018661,CDM,636,RC,J2310,HCPCS,641613225,NDC,,,,inpatient,facility,1,ML,19.8,19.8,1.58,19.8,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,19.8,,,percent of total billed charges,,,10.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.88,,,percent of total billed charges,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,16.83,,,percent of total billed charges,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,10.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.67,,,percent of total billed charges,,
NALOXONE HCL 0.4 MG/ML AMP,2500018661,CDM,636,RC,J2310,HCPCS,641613225,NDC,,,,outpatient,facility,1,ML,19.8,19.8,1.58,548.68,,14.04,,,percent of total billed charges,,,4.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,19.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.77,,,fee schedule,,,19.8,,,fee schedule,,,19.8,,,percent of total billed charges,,,,,,,,,19.8,,,percent of total billed charges,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,11.68,,,percent of total billed charges,,,548.68,,,per diem,,,19.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,19.8,,,percent of total billed charges,,,16.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.52,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.36,,,percent of total billed charges,,,16.02,,,percent of total billed charges,,,,,,,,,,,,,,,7.92,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,19.8,,,percent of total billed charges,,,19.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.58,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,9.69,,,fee schedule,,,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,19.8,,,percent of total billed charges,,,,,,,,,13.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.67,,,percent of total billed charges,,
NALOXONE HCL 0.4 MG/ML AMP,2500018661,CDM,636,RC,J2310,HCPCS,641613225,NDC,435,EAPG,,outpatient,facility,1,ML,19.8,19.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM CL 20 MEQ/100 ML IV,2500018670,CDM,636,RC,J3480,HCPCS,338070548,NDC,,,,inpatient,facility,100,ML,13.46,13.46,1.08,13.46,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,,,,,,,13.46,,,percent of total billed charges,,,6.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.08,,,percent of total billed charges,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,11.44,,,percent of total billed charges,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,7.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.93,,,percent of total billed charges,,
POTASSIUM CL 20 MEQ/100 ML IV,2500018670,CDM,636,RC,J3480,HCPCS,338070548,NDC,,,,outpatient,facility,100,ML,13.46,13.46,0.11,548.68,,9.54,,,percent of total billed charges,,,3.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.46,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.93,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.46,,,fee schedule,,,13.46,,,percent of total billed charges,,,,,,,,,13.46,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.94,,,percent of total billed charges,,,548.68,,,per diem,,,13.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.46,,,percent of total billed charges,,,11.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.15,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.08,,,percent of total billed charges,,,10.89,,,percent of total billed charges,,,,,,,,,,,,,,,5.38,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13.46,,,percent of total billed charges,,,13.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.08,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,13.46,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,,,,,,,9.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.93,,,percent of total billed charges,,
POTASSIUM CL 20 MEQ/100 ML IV,2500018670,CDM,636,RC,J3480,HCPCS,338070548,NDC,999,EAPG,,outpatient,facility,100,ML,13.46,13.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM CL 40 MEQ/100 ML IV,2500018673,CDM,636,RC,J3480,HCPCS,990707726,NDC,,,,inpatient,facility,100,ML,17.66,17.66,1.41,17.66,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,,,,,,,,17.66,,,percent of total billed charges,,,9.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.6,,,percent of total billed charges,,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,,15.01,,,percent of total billed charges,,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,,9.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,17.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.41,,,percent of total billed charges,,
POTASSIUM CL 40 MEQ/100 ML IV,2500018673,CDM,636,RC,J3480,HCPCS,990707726,NDC,,,,outpatient,facility,100,ML,17.66,17.66,0.11,548.68,,12.52,,,percent of total billed charges,,,4.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,17.66,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,17.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,17.66,,,fee schedule,,,17.66,,,percent of total billed charges,,,,,,,,,17.66,,,percent of total billed charges,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,10.42,,,percent of total billed charges,,,548.68,,,per diem,,,17.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,17.66,,,percent of total billed charges,,,15.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.38,,,percent of total billed charges,,,17.66,,,percent of total billed charges,,,17.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.91,,,percent of total billed charges,,,14.29,,,percent of total billed charges,,,,,,,,,,,,,,,7.06,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,17.66,,,percent of total billed charges,,,17.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.41,,,percent of total billed charges,,,17.66,,,percent of total billed charges,,,,,,,,,,,,,,,17.66,,,percent of total billed charges,,,17.66,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,17.66,,,percent of total billed charges,,,17.66,,,percent of total billed charges,,,17.66,,,percent of total billed charges,,,,,,,,,12.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.83,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.41,,,percent of total billed charges,,
POTASSIUM CL 40 MEQ/100 ML IV,2500018673,CDM,636,RC,J3480,HCPCS,990707726,NDC,999,EAPG,,outpatient,facility,100,ML,17.66,17.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GALANTAMINE HBR 4 MG TAB,2500018690,CDM,637,RC,7043600406,NDC,,,,,,inpatient,facility,4,UN,10.49,10.49,0.84,10.49,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,,,,,,,10.49,,,percent of total billed charges,,,5.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.29,,,percent of total billed charges,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,8.92,,,percent of total billed charges,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,5.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.18,,,percent of total billed charges,,
GALANTAMINE HBR 4 MG TAB,2500018690,CDM,637,RC,7043600406,NDC,,,,,,outpatient,facility,4,UN,10.49,10.49,0.84,548.68,,7.44,,,percent of total billed charges,,,2.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.49,,,percent of total billed charges,,,6.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.84,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.49,,,fee schedule,,,10.49,,,percent of total billed charges,,,,,,,,,10.49,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,percent of total billed charges,,,,,,,,,,,,,,,5.66,,,percent of total billed charges,,,5.45,,,percent of total billed charges,,,5.77,,,percent of total billed charges,,,,,,,,,6.19,,,percent of total billed charges,,,548.68,,,per diem,,,10.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.49,,,percent of total billed charges,,,8.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.57,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.08,,,percent of total billed charges,,,8.49,,,percent of total billed charges,,,,,,,,,,,,,,,4.2,,,percent of total billed charges,,,,,,,,,3.88,,,percent of total billed charges,,,3.88,,,percent of total billed charges,,,,,,,,,10.49,,,percent of total billed charges,,,10.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.84,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,,,,,,,,,,,,,10.49,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,,,,,,,9.76,,,percent of total billed charges,,,,,,,,,,,,,,,9.76,,,percent of total billed charges,,,9.76,,,percent of total billed charges,,,9.76,,,percent of total billed charges,,,7.87,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,10.49,,,percent of total billed charges,,,,,,,,,7.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.18,,,percent of total billed charges,,
GALANTAMINE HBR 4 MG TAB,2500018690,CDM,637,RC,7043600406,NDC,999,EAPG,,,,outpatient,facility,4,UN,10.49,10.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VALGANCICLOVIR 450 MG TAB,2500018710,CDM,637,RC,3172283260,NDC,,,,,,inpatient,facility,450,UN,212.52,212.52,17,212.52,,,,,,,,,,,,,,212.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,212.52,,,percent of total billed charges,,,,,,,,,212.52,,,percent of total billed charges,,,108.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.51,,,percent of total billed charges,,,,,,,,,,,,,,,212.52,,,percent of total billed charges,,,180.64,,,percent of total billed charges,,,,,,,,,,,,,,,212.52,,,percent of total billed charges,,,112.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,212.52,,,percent of total billed charges,,,,,,,,,,,,,,,17,,,percent of total billed charges,,,212.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,212.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.22,,,percent of total billed charges,,
VALGANCICLOVIR 450 MG TAB,2500018710,CDM,637,RC,3172283260,NDC,,,,,,outpatient,facility,450,UN,212.52,212.52,17,548.68,,150.7,,,percent of total billed charges,,,51.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,212.52,,,percent of total billed charges,,,133.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,149.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,149.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,212.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,77.78,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,212.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,212.52,,,fee schedule,,,212.52,,,percent of total billed charges,,,,,,,,,212.52,,,percent of total billed charges,,,130.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.42,,,percent of total billed charges,,,,,,,,,,,,,,,114.76,,,percent of total billed charges,,,110.51,,,percent of total billed charges,,,116.89,,,percent of total billed charges,,,,,,,,,125.39,,,percent of total billed charges,,,548.68,,,per diem,,,212.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,212.52,,,percent of total billed charges,,,180.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,112.87,,,percent of total billed charges,,,212.52,,,percent of total billed charges,,,212.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.37,,,percent of total billed charges,,,171.97,,,percent of total billed charges,,,,,,,,,,,,,,,85.01,,,percent of total billed charges,,,,,,,,,78.63,,,percent of total billed charges,,,78.63,,,percent of total billed charges,,,,,,,,,212.52,,,percent of total billed charges,,,212.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,212.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17,,,percent of total billed charges,,,212.52,,,percent of total billed charges,,,,,,,,,,,,,,,212.52,,,percent of total billed charges,,,212.52,,,percent of total billed charges,,,,,,,,,197.69,,,percent of total billed charges,,,,,,,,,,,,,,,197.69,,,percent of total billed charges,,,197.69,,,percent of total billed charges,,,197.69,,,percent of total billed charges,,,159.39,,,percent of total billed charges,,,212.52,,,percent of total billed charges,,,212.52,,,percent of total billed charges,,,212.52,,,percent of total billed charges,,,,,,,,,149,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.26,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,125.22,,,percent of total billed charges,,
VALGANCICLOVIR 450 MG TAB,2500018710,CDM,637,RC,3172283260,NDC,999,EAPG,,,,outpatient,facility,450,UN,212.52,212.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
COLESEVELAM HCL 625 MG TAB,2500018790,CDM,637,RC,6846243318,NDC,,,,,,inpatient,facility,625,UN,13.06,13.06,1.04,13.06,,,,,,,,,,,,,,13.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.06,,,percent of total billed charges,,,,,,,,,13.06,,,percent of total billed charges,,,6.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.84,,,percent of total billed charges,,,,,,,,,,,,,,,13.06,,,percent of total billed charges,,,11.1,,,percent of total billed charges,,,,,,,,,,,,,,,13.06,,,percent of total billed charges,,,6.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.06,,,percent of total billed charges,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,13.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.69,,,percent of total billed charges,,
COLESEVELAM HCL 625 MG TAB,2500018790,CDM,637,RC,6846243318,NDC,,,,,,outpatient,facility,625,UN,13.06,13.06,1.04,548.68,,9.26,,,percent of total billed charges,,,3.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.06,,,percent of total billed charges,,,8.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.78,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.06,,,fee schedule,,,13.06,,,percent of total billed charges,,,,,,,,,13.06,,,percent of total billed charges,,,8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.31,,,percent of total billed charges,,,,,,,,,,,,,,,7.05,,,percent of total billed charges,,,6.79,,,percent of total billed charges,,,7.18,,,percent of total billed charges,,,,,,,,,7.71,,,percent of total billed charges,,,548.68,,,per diem,,,13.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.06,,,percent of total billed charges,,,11.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.94,,,percent of total billed charges,,,13.06,,,percent of total billed charges,,,13.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.81,,,percent of total billed charges,,,10.57,,,percent of total billed charges,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,,,,,,,4.83,,,percent of total billed charges,,,4.83,,,percent of total billed charges,,,,,,,,,13.06,,,percent of total billed charges,,,13.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.04,,,percent of total billed charges,,,13.06,,,percent of total billed charges,,,,,,,,,,,,,,,13.06,,,percent of total billed charges,,,13.06,,,percent of total billed charges,,,,,,,,,12.15,,,percent of total billed charges,,,,,,,,,,,,,,,12.15,,,percent of total billed charges,,,12.15,,,percent of total billed charges,,,12.15,,,percent of total billed charges,,,9.79,,,percent of total billed charges,,,13.06,,,percent of total billed charges,,,13.06,,,percent of total billed charges,,,13.06,,,percent of total billed charges,,,,,,,,,9.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.69,,,percent of total billed charges,,
COLESEVELAM HCL 625 MG TAB,2500018790,CDM,637,RC,6846243318,NDC,999,EAPG,,,,outpatient,facility,625,UN,13.06,13.06,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VORICONAZOLE 200 MG INJ,2500018800,CDM,636,RC,J3465,HCPCS,781341694,NDC,,,,inpatient,facility,200,GR,503.51,503.51,40.28,503.51,,,,,,,,,,,,,,503.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,503.51,,,percent of total billed charges,,,,,,,,,503.51,,,percent of total billed charges,,,257.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,428.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.11,,,percent of total billed charges,,,,,,,,,,,,,,,503.51,,,percent of total billed charges,,,427.98,,,percent of total billed charges,,,,,,,,,,,,,,,503.51,,,percent of total billed charges,,,267.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,503.51,,,percent of total billed charges,,,,,,,,,,,,,,,40.28,,,percent of total billed charges,,,503.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,503.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.67,,,percent of total billed charges,,
VORICONAZOLE 200 MG INJ,2500018800,CDM,636,RC,J3465,HCPCS,781341694,NDC,,,,outpatient,facility,200,GR,503.51,503.51,0.73,548.68,,357.04,,,percent of total billed charges,,,122.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,503.51,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,503.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,184.28,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,503.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,503.51,,,fee schedule,,,503.51,,,percent of total billed charges,,,,,,,,,503.51,,,percent of total billed charges,,,308.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,fee schedule,,,1.16,,,fee schedule,,,1.16,,,fee schedule,,,,,,,,,297.07,,,percent of total billed charges,,,548.68,,,per diem,,,503.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,503.51,,,percent of total billed charges,,,427.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.41,,,percent of total billed charges,,,503.51,,,percent of total billed charges,,,503.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.67,,,percent of total billed charges,,,407.44,,,percent of total billed charges,,,,,,,,,,,,,,,201.4,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,503.51,,,percent of total billed charges,,,503.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,503.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.28,,,percent of total billed charges,,,503.51,,,percent of total billed charges,,,,,,,,,,,,,,,503.51,,,percent of total billed charges,,,503.51,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.73,,,fee schedule,,,503.51,,,percent of total billed charges,,,503.51,,,percent of total billed charges,,,503.51,,,percent of total billed charges,,,,,,,,,353.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,251.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,296.67,,,percent of total billed charges,,
VORICONAZOLE 200 MG INJ,2500018800,CDM,636,RC,J3465,HCPCS,781341694,NDC,435,EAPG,,outpatient,facility,200,GR,503.51,503.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VORICONAZOLE 200 MG TABLET,2500018803,CDM,637,RC,2724106303,NDC,,,,,,inpatient,facility,200,UN,262.42,262.42,20.99,262.42,,,,,,,,,,,,,,262.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.42,,,percent of total billed charges,,,,,,,,,262.42,,,percent of total billed charges,,,133.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.45,,,percent of total billed charges,,,,,,,,,,,,,,,262.42,,,percent of total billed charges,,,223.06,,,percent of total billed charges,,,,,,,,,,,,,,,262.42,,,percent of total billed charges,,,139.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,262.42,,,percent of total billed charges,,,,,,,,,,,,,,,20.99,,,percent of total billed charges,,,262.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,262.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.62,,,percent of total billed charges,,
VORICONAZOLE 200 MG TABLET,2500018803,CDM,637,RC,2724106303,NDC,,,,,,outpatient,facility,200,UN,262.42,262.42,20.99,548.68,,186.08,,,percent of total billed charges,,,64.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,262.42,,,percent of total billed charges,,,164.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,184.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,184.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,262.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,96.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,262.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,262.42,,,fee schedule,,,262.42,,,percent of total billed charges,,,,,,,,,262.42,,,percent of total billed charges,,,160.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.97,,,percent of total billed charges,,,,,,,,,,,,,,,141.71,,,percent of total billed charges,,,136.46,,,percent of total billed charges,,,144.33,,,percent of total billed charges,,,,,,,,,154.83,,,percent of total billed charges,,,548.68,,,per diem,,,262.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,262.42,,,percent of total billed charges,,,223.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,139.37,,,percent of total billed charges,,,262.42,,,percent of total billed charges,,,262.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.03,,,percent of total billed charges,,,212.35,,,percent of total billed charges,,,,,,,,,,,,,,,104.97,,,percent of total billed charges,,,,,,,,,97.1,,,percent of total billed charges,,,97.1,,,percent of total billed charges,,,,,,,,,262.42,,,percent of total billed charges,,,262.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,262.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.99,,,percent of total billed charges,,,262.42,,,percent of total billed charges,,,,,,,,,,,,,,,262.42,,,percent of total billed charges,,,262.42,,,percent of total billed charges,,,,,,,,,244.1,,,percent of total billed charges,,,,,,,,,,,,,,,244.1,,,percent of total billed charges,,,244.1,,,percent of total billed charges,,,244.1,,,percent of total billed charges,,,196.81,,,percent of total billed charges,,,262.42,,,percent of total billed charges,,,262.42,,,percent of total billed charges,,,262.42,,,percent of total billed charges,,,,,,,,,183.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,154.62,,,percent of total billed charges,,
VORICONAZOLE 200 MG TABLET,2500018803,CDM,637,RC,2724106303,NDC,999,EAPG,,,,outpatient,facility,200,UN,262.42,262.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
KIT EMTRICTB/TENOFVR/RALTEGRVR,2500018813,CDM,637,RC,4238595330,NDC,,,,,,inpatient,facility,1,UN,1099.69,1099.69,87.98,1099.69,,,,,,,,,,,,,,1099.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1099.69,,,percent of total billed charges,,,,,,,,,1099.69,,,percent of total billed charges,,,561.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,936.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,659.81,,,percent of total billed charges,,,,,,,,,,,,,,,1099.69,,,percent of total billed charges,,,934.74,,,percent of total billed charges,,,,,,,,,,,,,,,1099.69,,,percent of total billed charges,,,584.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,439.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1099.69,,,percent of total billed charges,,,,,,,,,,,,,,,87.98,,,percent of total billed charges,,,1099.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1099.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,647.94,,,percent of total billed charges,,
KIT EMTRICTB/TENOFVR/RALTEGRVR,2500018813,CDM,637,RC,4238595330,NDC,,,,,,outpatient,facility,1,UN,1099.69,1099.69,87.98,1099.69,,779.79,,,percent of total billed charges,,,268.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1099.69,,,percent of total billed charges,,,689.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,773.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,773.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1099.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,402.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1099.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1099.69,,,fee schedule,,,1099.69,,,percent of total billed charges,,,,,,,,,1099.69,,,percent of total billed charges,,,674,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,783.53,,,percent of total billed charges,,,,,,,,,,,,,,,593.83,,,percent of total billed charges,,,571.84,,,percent of total billed charges,,,604.83,,,percent of total billed charges,,,,,,,,,648.82,,,percent of total billed charges,,,548.68,,,per diem,,,1099.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1099.69,,,percent of total billed charges,,,934.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,584.05,,,percent of total billed charges,,,1099.69,,,percent of total billed charges,,,1099.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,741.85,,,percent of total billed charges,,,889.87,,,percent of total billed charges,,,,,,,,,,,,,,,439.88,,,percent of total billed charges,,,,,,,,,406.89,,,percent of total billed charges,,,406.89,,,percent of total billed charges,,,,,,,,,1099.69,,,percent of total billed charges,,,1099.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1099.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,87.98,,,percent of total billed charges,,,1099.69,,,percent of total billed charges,,,,,,,,,,,,,,,1099.69,,,percent of total billed charges,,,1099.69,,,percent of total billed charges,,,,,,,,,1022.93,,,percent of total billed charges,,,,,,,,,,,,,,,1022.93,,,percent of total billed charges,,,1022.93,,,percent of total billed charges,,,1022.93,,,percent of total billed charges,,,824.77,,,percent of total billed charges,,,1099.69,,,percent of total billed charges,,,1099.69,,,percent of total billed charges,,,1099.69,,,percent of total billed charges,,,,,,,,,770.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,549.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,647.94,,,percent of total billed charges,,
KIT EMTRICTB/TENOFVR/RALTEGRVR,2500018813,CDM,637,RC,4238595330,NDC,999,EAPG,,,,outpatient,facility,1,UN,1099.69,1099.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EMTRICITAB/TENOF 200/300MG TAB,2500018815,CDM,637,RC,4238595330,NDC,,,,,,inpatient,facility,1,UN,231.03,231.03,18.48,231.03,,,,,,,,,,,,,,231.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.03,,,percent of total billed charges,,,,,,,,,231.03,,,percent of total billed charges,,,117.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.62,,,percent of total billed charges,,,,,,,,,,,,,,,231.03,,,percent of total billed charges,,,196.38,,,percent of total billed charges,,,,,,,,,,,,,,,231.03,,,percent of total billed charges,,,122.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,231.03,,,percent of total billed charges,,,,,,,,,,,,,,,18.48,,,percent of total billed charges,,,231.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,231.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.12,,,percent of total billed charges,,
EMTRICITAB/TENOF 200/300MG TAB,2500018815,CDM,637,RC,4238595330,NDC,,,,,,outpatient,facility,1,UN,231.03,231.03,18.48,548.68,,163.82,,,percent of total billed charges,,,56.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,231.03,,,percent of total billed charges,,,144.79,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,162.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,162.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,231.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,84.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,231.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,231.03,,,fee schedule,,,231.03,,,percent of total billed charges,,,,,,,,,231.03,,,percent of total billed charges,,,141.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.61,,,percent of total billed charges,,,,,,,,,,,,,,,124.76,,,percent of total billed charges,,,120.14,,,percent of total billed charges,,,127.07,,,percent of total billed charges,,,,,,,,,136.31,,,percent of total billed charges,,,548.68,,,per diem,,,231.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,231.03,,,percent of total billed charges,,,196.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,122.7,,,percent of total billed charges,,,231.03,,,percent of total billed charges,,,231.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.85,,,percent of total billed charges,,,186.95,,,percent of total billed charges,,,,,,,,,,,,,,,92.41,,,percent of total billed charges,,,,,,,,,85.48,,,percent of total billed charges,,,85.48,,,percent of total billed charges,,,,,,,,,231.03,,,percent of total billed charges,,,231.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,231.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.48,,,percent of total billed charges,,,231.03,,,percent of total billed charges,,,,,,,,,,,,,,,231.03,,,percent of total billed charges,,,231.03,,,percent of total billed charges,,,,,,,,,214.9,,,percent of total billed charges,,,,,,,,,,,,,,,214.9,,,percent of total billed charges,,,214.9,,,percent of total billed charges,,,214.9,,,percent of total billed charges,,,173.27,,,percent of total billed charges,,,231.03,,,percent of total billed charges,,,231.03,,,percent of total billed charges,,,231.03,,,percent of total billed charges,,,,,,,,,161.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,136.12,,,percent of total billed charges,,
EMTRICITAB/TENOF 200/300MG TAB,2500018815,CDM,637,RC,4238595330,NDC,999,EAPG,,,,outpatient,facility,1,UN,231.03,231.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ELVITEGR/COBCST/EMTR/TENOF TAB,2500018816,CDM,637,RC,6195819011,NDC,,,,,,inpatient,facility,1,UN,437.94,437.94,35.04,437.94,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,437.94,,,percent of total billed charges,,,223.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.76,,,percent of total billed charges,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,372.25,,,percent of total billed charges,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,232.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,35.04,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258.03,,,percent of total billed charges,,
ELVITEGR/COBCST/EMTR/TENOF TAB,2500018816,CDM,637,RC,6195819011,NDC,,,,,,outpatient,facility,1,UN,437.94,437.94,35.04,548.68,,310.54,,,percent of total billed charges,,,106.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,437.94,,,percent of total billed charges,,,274.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,307.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,307.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,160.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,437.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,437.94,,,fee schedule,,,437.94,,,percent of total billed charges,,,,,,,,,437.94,,,percent of total billed charges,,,268.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,312.03,,,percent of total billed charges,,,,,,,,,,,,,,,236.49,,,percent of total billed charges,,,227.73,,,percent of total billed charges,,,240.87,,,percent of total billed charges,,,,,,,,,258.38,,,percent of total billed charges,,,548.68,,,per diem,,,437.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,437.94,,,percent of total billed charges,,,372.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.59,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,295.43,,,percent of total billed charges,,,354.38,,,percent of total billed charges,,,,,,,,,,,,,,,175.18,,,percent of total billed charges,,,,,,,,,162.04,,,percent of total billed charges,,,162.04,,,percent of total billed charges,,,,,,,,,437.94,,,percent of total billed charges,,,437.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,437.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.04,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,407.37,,,percent of total billed charges,,,,,,,,,,,,,,,407.37,,,percent of total billed charges,,,407.37,,,percent of total billed charges,,,407.37,,,percent of total billed charges,,,328.45,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,307.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,258.03,,,percent of total billed charges,,
ELVITEGR/COBCST/EMTR/TENOF TAB,2500018816,CDM,637,RC,6195819011,NDC,999,EAPG,,,,outpatient,facility,1,UN,437.94,437.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ERTAPENEM  SOD PER 1 GM,2500018820,CDM,636,RC,J1335,HCPCS,4202322110,NDC,,,,inpatient,facility,1000,UN,386.33,386.33,30.91,386.33,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,,,,,,,386.33,,,percent of total billed charges,,,197.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,329.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.8,,,percent of total billed charges,,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,328.38,,,percent of total billed charges,,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,205.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,30.91,,,percent of total billed charges,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.63,,,percent of total billed charges,,
ERTAPENEM  SOD PER 1 GM,2500018820,CDM,636,RC,J1335,HCPCS,4202322110,NDC,,,,outpatient,facility,1000,UN,386.33,386.33,11.14,548.68,,273.95,,,percent of total billed charges,,,94.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,386.33,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,141.4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,386.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,386.33,,,fee schedule,,,386.33,,,percent of total billed charges,,,,,,,,,386.33,,,percent of total billed charges,,,236.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,275.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,227.93,,,percent of total billed charges,,,548.68,,,per diem,,,386.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,386.33,,,percent of total billed charges,,,328.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.18,,,percent of total billed charges,,,386.33,,,percent of total billed charges,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,260.62,,,percent of total billed charges,,,312.62,,,percent of total billed charges,,,,,,,,,,,,,,,154.53,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,386.33,,,percent of total billed charges,,,386.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,386.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.91,,,percent of total billed charges,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,11.14,,,fee schedule,,,386.33,,,percent of total billed charges,,,386.33,,,percent of total billed charges,,,386.33,,,percent of total billed charges,,,,,,,,,270.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,227.63,,,percent of total billed charges,,
ERTAPENEM  SOD PER 1 GM,2500018820,CDM,636,RC,J1335,HCPCS,4202322110,NDC,999,EAPG,,outpatient,facility,1000,UN,386.33,386.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEGFILGRASTIM INJ 6 MG,2500018832,CDM,636,RC,J2506,HCPCS,5551319001,NDC,,,,inpatient,facility,0.6,ML,21179.37,21179.37,1694.35,21179.37,,,,,,,,,,,,,,21179.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21179.37,,,percent of total billed charges,,,,,,,,,21179.37,,,percent of total billed charges,,,10814.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18038.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12707.62,,,percent of total billed charges,,,,,,,,,,,,,,,21179.37,,,percent of total billed charges,,,18002.46,,,percent of total billed charges,,,,,,,,,,,,,,,21179.37,,,percent of total billed charges,,,11248.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8471.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,21179.37,,,percent of total billed charges,,,,,,,,,,,,,,,1694.35,,,percent of total billed charges,,,21179.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21179.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12478.88,,,percent of total billed charges,,
PEGFILGRASTIM INJ 6 MG,2500018832,CDM,636,RC,J2506,HCPCS,5551319001,NDC,,,,outpatient,facility,0.6,ML,21179.37,21179.37,19.98,21179.37,,15018.29,,,percent of total billed charges,,,,,,,,,21179.37,,,percent of total billed charges,,,71.56,,,fee schedule,,,67.7,,,fee schedule,,,,,,,,,67.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,21179.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,21179.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,19.98,,,fee schedule,,,21179.37,,,percent of total billed charges,,,,,,,,,21179.37,,,percent of total billed charges,,,12980.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15090.3,,,percent of total billed charges,,,,,,,,,,,,,,,50.68,,,fee schedule,,,50.68,,,fee schedule,,,50.68,,,fee schedule,,,,,,,,,12495.83,,,percent of total billed charges,,,548.68,,,per diem,,,21179.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,21179.37,,,percent of total billed charges,,,18002.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11248.36,,,percent of total billed charges,,,21179.37,,,percent of total billed charges,,,21179.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14287.6,,,percent of total billed charges,,,17138.35,,,percent of total billed charges,,,,,,,,,,,,,,,8471.75,,,percent of total billed charges,,,,,,,,,322.87,,,fee schedule,,,232.33,,,fee schedule,,,,,,,,,21179.37,,,percent of total billed charges,,,,,,,,,,,,,,,1694.35,,,percent of total billed charges,,,21179.37,,,percent of total billed charges,,,,,,,,,,,,,,,21179.37,,,percent of total billed charges,,,21179.37,,,percent of total billed charges,,,,,,,,,137.98,,,fee schedule,,,,,,,,,,,,,,,119.59,,,fee schedule,,,159.45,,,fee schedule,,,89.69,,,fee schedule,,,57.21,,,fee schedule,,,21179.37,,,percent of total billed charges,,,21179.37,,,percent of total billed charges,,,21179.37,,,percent of total billed charges,,,,,,,,,14848.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10589.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,12478.88,,,percent of total billed charges,,
PEGFILGRASTIM INJ 6 MG,2500018832,CDM,636,RC,J2506,HCPCS,5551319001,NDC,9436,APC,,outpatient,facility,0.6,ML,21179.37,21179.37,19.18,29.97,,,,,,,,20.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.18,,,fee schedule,,,,,,,,,22.6,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,,,,,,,20.98,,,fee schedule,,,20.98,,,fee schedule,,,,,,,,,19.98,,,fee schedule,,,19.98,,,fee schedule,,,20.98,,,fee schedule,,,,,,,,,,,,,,,29.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.18,,,fee schedule,,,21.38,,,fee schedule,,,20.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,19.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,20.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,24.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,19.98,,,fee schedule,,,19.98,,,fee schedule,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,19.98,,,fee schedule,,,20.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,19.66,,,fee schedule,,,20.78,,,fee schedule,,,19.98,,,fee schedule,,,19.66,,,fee schedule,,,19.98,,,fee schedule,,,,,,,,,19.98,,,fee schedule,,,20.98,,,fee schedule,,,,,,,,
PEGFILGRASTIM INJ 6 MG,2500018832,CDM,636,RC,J2506,HCPCS,5551319001,NDC,461,EAPG,,outpatient,facility,0.6,ML,21179.37,21179.37,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HYDROMORPHONE 0.2MG/ML 30MLPCA,2500018840,CDM,636,RC,J1171,HCPCS,6155316141,NDC,,,,inpatient,facility,30,ML,22.54,22.54,1.8,22.54,,,,,,,,,,,,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.54,,,percent of total billed charges,,,,,,,,,22.54,,,percent of total billed charges,,,11.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.52,,,percent of total billed charges,,,,,,,,,,,,,,,22.54,,,percent of total billed charges,,,19.16,,,percent of total billed charges,,,,,,,,,,,,,,,22.54,,,percent of total billed charges,,,11.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.28,,,percent of total billed charges,,
HYDROMORPHONE 0.2MG/ML 30MLPCA,2500018840,CDM,636,RC,J1171,HCPCS,6155316141,NDC,,,,outpatient,facility,30,ML,22.54,22.54,1.8,548.68,,15.98,,,percent of total billed charges,,,,,,,,,22.54,,,percent of total billed charges,,,14.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,15.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,15.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,22.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,22.54,,,fee schedule,,,22.54,,,percent of total billed charges,,,,,,,,,22.54,,,percent of total billed charges,,,13.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.06,,,percent of total billed charges,,,,,,,,,,,,,,,12.17,,,percent of total billed charges,,,11.72,,,percent of total billed charges,,,12.4,,,percent of total billed charges,,,,,,,,,13.3,,,percent of total billed charges,,,548.68,,,per diem,,,22.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,22.54,,,percent of total billed charges,,,19.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.97,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,18.24,,,percent of total billed charges,,,,,,,,,,,,,,,9.02,,,percent of total billed charges,,,,,,,,,8.34,,,percent of total billed charges,,,8.34,,,percent of total billed charges,,,,,,,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.8,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,,,,,,,22.54,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,20.97,,,percent of total billed charges,,,,,,,,,,,,,,,20.97,,,percent of total billed charges,,,20.97,,,percent of total billed charges,,,20.97,,,percent of total billed charges,,,16.91,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,22.54,,,percent of total billed charges,,,,,,,,,15.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.27,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.28,,,percent of total billed charges,,
HYDROMORPHONE 0.2MG/ML 30MLPCA,2500018840,CDM,636,RC,J1171,HCPCS,6155316141,NDC,791,APC,,outpatient,facility,30,ML,22.54,22.54,0.09,8.25,,,,,,,,0.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,8.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.1,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,fee schedule,,,,,,,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,,,,,,,0.09,,,fee schedule,,,0.09,,,fee schedule,,,,,,,,
HYDROMORPHONE 0.2MG/ML 30MLPCA,2500018840,CDM,636,RC,J1171,HCPCS,6155316141,NDC,999,EAPG,,outpatient,facility,30,ML,22.54,22.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EXEMESTANE 25 MG TAB,2500018850,CDM,637,RC,6838238306,NDC,,,,,,inpatient,facility,25,UN,66.76,66.76,5.34,66.76,,,,,,,,,,,,,,66.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.76,,,percent of total billed charges,,,,,,,,,66.76,,,percent of total billed charges,,,34.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.06,,,percent of total billed charges,,,,,,,,,,,,,,,66.76,,,percent of total billed charges,,,56.75,,,percent of total billed charges,,,,,,,,,,,,,,,66.76,,,percent of total billed charges,,,35.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,66.76,,,percent of total billed charges,,,,,,,,,,,,,,,5.34,,,percent of total billed charges,,,66.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.33,,,percent of total billed charges,,
EXEMESTANE 25 MG TAB,2500018850,CDM,637,RC,6838238306,NDC,,,,,,outpatient,facility,25,UN,66.76,66.76,5.34,548.68,,47.34,,,percent of total billed charges,,,16.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,66.76,,,percent of total billed charges,,,41.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,46.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,46.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,66.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,24.43,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,66.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,66.76,,,fee schedule,,,66.76,,,percent of total billed charges,,,,,,,,,66.76,,,percent of total billed charges,,,40.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.57,,,percent of total billed charges,,,,,,,,,,,,,,,36.05,,,percent of total billed charges,,,34.72,,,percent of total billed charges,,,36.72,,,percent of total billed charges,,,,,,,,,39.39,,,percent of total billed charges,,,548.68,,,per diem,,,66.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,66.76,,,percent of total billed charges,,,56.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.46,,,percent of total billed charges,,,66.76,,,percent of total billed charges,,,66.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.04,,,percent of total billed charges,,,54.02,,,percent of total billed charges,,,,,,,,,,,,,,,26.7,,,percent of total billed charges,,,,,,,,,24.7,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,66.76,,,percent of total billed charges,,,66.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,66.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.34,,,percent of total billed charges,,,66.76,,,percent of total billed charges,,,,,,,,,,,,,,,66.76,,,percent of total billed charges,,,66.76,,,percent of total billed charges,,,,,,,,,62.1,,,percent of total billed charges,,,,,,,,,,,,,,,62.1,,,percent of total billed charges,,,62.1,,,percent of total billed charges,,,62.1,,,percent of total billed charges,,,50.07,,,percent of total billed charges,,,66.76,,,percent of total billed charges,,,66.76,,,percent of total billed charges,,,66.76,,,percent of total billed charges,,,,,,,,,46.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,39.33,,,percent of total billed charges,,
EXEMESTANE 25 MG TAB,2500018850,CDM,637,RC,6838238306,NDC,999,EAPG,,,,outpatient,facility,25,UN,66.76,66.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TESTOSTERONE 1   GEL 5 GM,2500018885,CDM,637,RC,591321730,NDC,,,,,,inpatient,facility,1,UN,9.9,9.9,0.79,9.9,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,5.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,5.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.83,,,percent of total billed charges,,
TESTOSTERONE 1   GEL 5 GM,2500018885,CDM,637,RC,591321730,NDC,,,,,,outpatient,facility,1,UN,9.9,9.9,0.79,548.68,,7.02,,,percent of total billed charges,,,2.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.9,,,percent of total billed charges,,,6.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.62,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.9,,,fee schedule,,,9.9,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.05,,,percent of total billed charges,,,,,,,,,,,,,,,5.35,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,5.45,,,percent of total billed charges,,,,,,,,,5.84,,,percent of total billed charges,,,548.68,,,per diem,,,9.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.9,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.26,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.68,,,percent of total billed charges,,,8.01,,,percent of total billed charges,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,3.66,,,percent of total billed charges,,,3.66,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,9.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.79,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,9.21,,,percent of total billed charges,,,7.43,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,6.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.83,,,percent of total billed charges,,
TESTOSTERONE 1   GEL 5 GM,2500018885,CDM,637,RC,591321730,NDC,999,EAPG,,,,outpatient,facility,1,UN,9.9,9.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ARIPIPRAZOLE 10 MG TAB,2500018894,CDM,637,RC,6516289803,NDC,,,,,,inpatient,facility,10,UN,105.86,105.86,8.47,105.86,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,105.86,,,percent of total billed charges,,,54.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,89.98,,,percent of total billed charges,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,56.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,8.47,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.37,,,percent of total billed charges,,
ARIPIPRAZOLE 10 MG TAB,2500018894,CDM,637,RC,6516289803,NDC,,,,,,outpatient,facility,10,UN,105.86,105.86,8.47,548.68,,75.07,,,percent of total billed charges,,,25.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,105.86,,,percent of total billed charges,,,66.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,74.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,74.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,38.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,105.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,105.86,,,fee schedule,,,105.86,,,percent of total billed charges,,,,,,,,,105.86,,,percent of total billed charges,,,64.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.43,,,percent of total billed charges,,,,,,,,,,,,,,,57.16,,,percent of total billed charges,,,55.05,,,percent of total billed charges,,,58.22,,,percent of total billed charges,,,,,,,,,62.46,,,percent of total billed charges,,,548.68,,,per diem,,,105.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,105.86,,,percent of total billed charges,,,89.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.22,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.41,,,percent of total billed charges,,,85.66,,,percent of total billed charges,,,,,,,,,,,,,,,42.34,,,percent of total billed charges,,,,,,,,,39.17,,,percent of total billed charges,,,39.17,,,percent of total billed charges,,,,,,,,,105.86,,,percent of total billed charges,,,105.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,105.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.47,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,98.47,,,percent of total billed charges,,,,,,,,,,,,,,,98.47,,,percent of total billed charges,,,98.47,,,percent of total billed charges,,,98.47,,,percent of total billed charges,,,79.39,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,74.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,62.37,,,percent of total billed charges,,
ARIPIPRAZOLE 10 MG TAB,2500018894,CDM,637,RC,6516289803,NDC,999,EAPG,,,,outpatient,facility,10,UN,105.86,105.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ARIPIPRAZOLE 5 MG TAB,2500018896,CDM,637,RC,6516289709,NDC,,,,,,inpatient,facility,5,UN,105.86,105.86,8.47,105.86,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,105.86,,,percent of total billed charges,,,54.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,89.98,,,percent of total billed charges,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,56.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,8.47,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.37,,,percent of total billed charges,,
ARIPIPRAZOLE 5 MG TAB,2500018896,CDM,637,RC,6516289709,NDC,,,,,,outpatient,facility,5,UN,105.86,105.86,8.47,548.68,,75.07,,,percent of total billed charges,,,25.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,105.86,,,percent of total billed charges,,,66.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,74.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,74.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,38.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,105.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,105.86,,,fee schedule,,,105.86,,,percent of total billed charges,,,,,,,,,105.86,,,percent of total billed charges,,,64.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.43,,,percent of total billed charges,,,,,,,,,,,,,,,57.16,,,percent of total billed charges,,,55.05,,,percent of total billed charges,,,58.22,,,percent of total billed charges,,,,,,,,,62.46,,,percent of total billed charges,,,548.68,,,per diem,,,105.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,105.86,,,percent of total billed charges,,,89.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.22,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.41,,,percent of total billed charges,,,85.66,,,percent of total billed charges,,,,,,,,,,,,,,,42.34,,,percent of total billed charges,,,,,,,,,39.17,,,percent of total billed charges,,,39.17,,,percent of total billed charges,,,,,,,,,105.86,,,percent of total billed charges,,,105.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,105.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.47,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,98.47,,,percent of total billed charges,,,,,,,,,,,,,,,98.47,,,percent of total billed charges,,,98.47,,,percent of total billed charges,,,98.47,,,percent of total billed charges,,,79.39,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,74.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,62.37,,,percent of total billed charges,,
ARIPIPRAZOLE 5 MG TAB,2500018896,CDM,637,RC,6516289709,NDC,999,EAPG,,,,outpatient,facility,5,UN,105.86,105.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ARIPIPRAZOLE 2 MG TAB,2500018897,CDM,637,RC,6516289603,NDC,,,,,,inpatient,facility,2,UN,105.86,105.86,8.47,105.86,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,105.86,,,percent of total billed charges,,,54.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.52,,,percent of total billed charges,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,89.98,,,percent of total billed charges,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,56.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,8.47,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.37,,,percent of total billed charges,,
ARIPIPRAZOLE 2 MG TAB,2500018897,CDM,637,RC,6516289603,NDC,,,,,,outpatient,facility,2,UN,105.86,105.86,8.47,548.68,,75.07,,,percent of total billed charges,,,25.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,105.86,,,percent of total billed charges,,,66.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,74.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,74.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,38.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,105.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,105.86,,,fee schedule,,,105.86,,,percent of total billed charges,,,,,,,,,105.86,,,percent of total billed charges,,,64.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.43,,,percent of total billed charges,,,,,,,,,,,,,,,57.16,,,percent of total billed charges,,,55.05,,,percent of total billed charges,,,58.22,,,percent of total billed charges,,,,,,,,,62.46,,,percent of total billed charges,,,548.68,,,per diem,,,105.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,105.86,,,percent of total billed charges,,,89.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.22,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.41,,,percent of total billed charges,,,85.66,,,percent of total billed charges,,,,,,,,,,,,,,,42.34,,,percent of total billed charges,,,,,,,,,39.17,,,percent of total billed charges,,,39.17,,,percent of total billed charges,,,,,,,,,105.86,,,percent of total billed charges,,,105.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,105.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.47,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,,,,,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,98.47,,,percent of total billed charges,,,,,,,,,,,,,,,98.47,,,percent of total billed charges,,,98.47,,,percent of total billed charges,,,98.47,,,percent of total billed charges,,,79.39,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,105.86,,,percent of total billed charges,,,,,,,,,74.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,62.37,,,percent of total billed charges,,
ARIPIPRAZOLE 2 MG TAB,2500018897,CDM,637,RC,6516289603,NDC,999,EAPG,,,,outpatient,facility,2,UN,105.86,105.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FONDAPARINUX 2.5 MG INJ,2500018900,CDM,636,RC,J1652,HCPCS,5515023010,NDC,,,,inpatient,facility,0.5,UN,118.8,118.8,9.5,118.8,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,118.8,,,percent of total billed charges,,,60.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.28,,,percent of total billed charges,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,63.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70,,,percent of total billed charges,,
FONDAPARINUX 2.5 MG INJ,2500018900,CDM,636,RC,J1652,HCPCS,5515023010,NDC,,,,outpatient,facility,0.5,UN,118.8,118.8,1.12,548.68,,84.24,,,percent of total billed charges,,,28.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,118.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,43.48,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,118.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,118.8,,,fee schedule,,,118.8,,,percent of total billed charges,,,,,,,,,118.8,,,percent of total billed charges,,,72.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,70.09,,,percent of total billed charges,,,548.68,,,per diem,,,118.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,118.8,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.09,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.14,,,percent of total billed charges,,,96.13,,,percent of total billed charges,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,118.8,,,percent of total billed charges,,,118.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,118.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.5,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,118.8,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.12,,,fee schedule,,,118.8,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,118.8,,,percent of total billed charges,,,,,,,,,83.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,70,,,percent of total billed charges,,
FONDAPARINUX 2.5 MG INJ,2500018900,CDM,636,RC,J1652,HCPCS,5515023010,NDC,496,EAPG,,outpatient,facility,0.5,UN,118.8,118.8,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FONDAPARINUX 5 MG INJ,2500018901,CDM,636,RC,J1652,HCPCS,5515023110,NDC,,,,inpatient,facility,0.4,UN,287.6,287.6,23.01,287.6,,,,,,,,,,,,,,287.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.6,,,percent of total billed charges,,,,,,,,,287.6,,,percent of total billed charges,,,146.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,244.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.56,,,percent of total billed charges,,,,,,,,,,,,,,,287.6,,,percent of total billed charges,,,244.46,,,percent of total billed charges,,,,,,,,,,,,,,,287.6,,,percent of total billed charges,,,152.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,287.6,,,percent of total billed charges,,,,,,,,,,,,,,,23.01,,,percent of total billed charges,,,287.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,287.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.45,,,percent of total billed charges,,
FONDAPARINUX 5 MG INJ,2500018901,CDM,636,RC,J1652,HCPCS,5515023110,NDC,,,,outpatient,facility,0.4,UN,287.6,287.6,1.12,548.68,,203.94,,,percent of total billed charges,,,70.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,287.6,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,287.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,105.26,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,287.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,287.6,,,fee schedule,,,287.6,,,percent of total billed charges,,,,,,,,,287.6,,,percent of total billed charges,,,176.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,204.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,169.68,,,percent of total billed charges,,,548.68,,,per diem,,,287.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,287.6,,,percent of total billed charges,,,244.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,152.74,,,percent of total billed charges,,,287.6,,,percent of total billed charges,,,287.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.01,,,percent of total billed charges,,,232.73,,,percent of total billed charges,,,,,,,,,,,,,,,115.04,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,287.6,,,percent of total billed charges,,,287.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,287.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.01,,,percent of total billed charges,,,287.6,,,percent of total billed charges,,,,,,,,,,,,,,,287.6,,,percent of total billed charges,,,287.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.12,,,fee schedule,,,287.6,,,percent of total billed charges,,,287.6,,,percent of total billed charges,,,287.6,,,percent of total billed charges,,,,,,,,,201.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,169.45,,,percent of total billed charges,,
FONDAPARINUX 5 MG INJ,2500018901,CDM,636,RC,J1652,HCPCS,5515023110,NDC,496,EAPG,,outpatient,facility,0.4,UN,287.6,287.6,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FORMOTEROL 20 MCG NEB,2500018904,CDM,637,RC,J7606,HCPCS,4950260561,NDC,,,,inpatient,facility,2,UN,64.18,64.18,5.13,64.18,,,,,,,,,,,,,,64.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.18,,,percent of total billed charges,,,,,,,,,64.18,,,percent of total billed charges,,,32.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.51,,,percent of total billed charges,,,,,,,,,,,,,,,64.18,,,percent of total billed charges,,,54.55,,,percent of total billed charges,,,,,,,,,,,,,,,64.18,,,percent of total billed charges,,,34.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,64.18,,,percent of total billed charges,,,,,,,,,,,,,,,5.13,,,percent of total billed charges,,,64.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.81,,,percent of total billed charges,,
FORMOTEROL 20 MCG NEB,2500018904,CDM,637,RC,J7606,HCPCS,4950260561,NDC,,,,outpatient,facility,2,UN,64.18,64.18,2.38,548.68,,45.51,,,percent of total billed charges,,,15.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,64.18,,,percent of total billed charges,,,4.09,,,fee schedule,,,3.87,,,fee schedule,,,,,,,,,3.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,64.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,23.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,64.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.38,,,fee schedule,,,64.18,,,percent of total billed charges,,,,,,,,,64.18,,,percent of total billed charges,,,39.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.73,,,percent of total billed charges,,,,,,,,,,,,,,,4.1,,,fee schedule,,,4.1,,,fee schedule,,,4.1,,,fee schedule,,,,,,,,,37.87,,,percent of total billed charges,,,548.68,,,per diem,,,64.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,64.18,,,percent of total billed charges,,,54.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.09,,,percent of total billed charges,,,64.18,,,percent of total billed charges,,,64.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.3,,,percent of total billed charges,,,51.93,,,percent of total billed charges,,,,,,,,,,,,,,,25.67,,,percent of total billed charges,,,,,,,,,16.66,,,fee schedule,,,11.99,,,fee schedule,,,,,,,,,64.18,,,percent of total billed charges,,,64.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,64.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.13,,,percent of total billed charges,,,64.18,,,percent of total billed charges,,,,,,,,,,,,,,,64.18,,,percent of total billed charges,,,64.18,,,percent of total billed charges,,,,,,,,,7.12,,,fee schedule,,,,,,,,,,,,,,,6.17,,,fee schedule,,,8.23,,,fee schedule,,,4.63,,,fee schedule,,,3.27,,,fee schedule,,,64.18,,,percent of total billed charges,,,64.18,,,percent of total billed charges,,,64.18,,,percent of total billed charges,,,,,,,,,45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,37.81,,,percent of total billed charges,,
FORMOTEROL 20 MCG NEB,2500018904,CDM,637,RC,J7606,HCPCS,4950260561,NDC,999,EAPG,,outpatient,facility,2,UN,64.18,64.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE D5W 2 GM 250 ML,2500018912,CDM,636,RC,J2002,HCPCS,264959820,NDC,,,,inpatient,facility,250,UN,25.34,25.34,2.03,25.34,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,,,,,,,25.34,,,percent of total billed charges,,,12.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,21.54,,,percent of total billed charges,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.93,,,percent of total billed charges,,
LIDOCAINE D5W 2 GM 250 ML,2500018912,CDM,636,RC,J2002,HCPCS,264959820,NDC,,,,outpatient,facility,250,UN,25.34,25.34,2.03,548.68,,17.97,,,percent of total billed charges,,,,,,,,,25.34,,,percent of total billed charges,,,15.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,17.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,17.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,25.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,25.34,,,fee schedule,,,25.34,,,percent of total billed charges,,,,,,,,,25.34,,,percent of total billed charges,,,15.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,13.68,,,percent of total billed charges,,,13.18,,,percent of total billed charges,,,13.94,,,percent of total billed charges,,,,,,,,,14.95,,,percent of total billed charges,,,548.68,,,per diem,,,25.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,25.34,,,percent of total billed charges,,,21.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.09,,,percent of total billed charges,,,20.51,,,percent of total billed charges,,,,,,,,,,,,,,,10.14,,,percent of total billed charges,,,,,,,,,9.38,,,percent of total billed charges,,,9.38,,,percent of total billed charges,,,,,,,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,25.34,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,,,,,,,23.57,,,percent of total billed charges,,,,,,,,,,,,,,,23.57,,,percent of total billed charges,,,23.57,,,percent of total billed charges,,,23.57,,,percent of total billed charges,,,19,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,,,,,,,17.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.67,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.93,,,percent of total billed charges,,
LIDOCAINE D5W 2 GM 250 ML,2500018912,CDM,636,RC,J2002,HCPCS,264959820,NDC,795,APC,,outpatient,facility,250,UN,25.34,25.34,9.27,9.27,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,9.27,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,
LIDOCAINE D5W 2 GM 250 ML,2500018912,CDM,636,RC,J2002,HCPCS,264959820,NDC,999,EAPG,,outpatient,facility,250,UN,25.34,25.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXALIPLATIN 100 MG INJ,2500018943,CDM,636,RC,J9263,HCPCS,6170336250,NDC,,,,inpatient,facility,100,GR,792,792,63.36,792,,,,,,,,,,,,,,792,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,792,,,percent of total billed charges,,,,,,,,,792,,,percent of total billed charges,,,404.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,475.2,,,percent of total billed charges,,,,,,,,,,,,,,,792,,,percent of total billed charges,,,673.2,,,percent of total billed charges,,,,,,,,,,,,,,,792,,,percent of total billed charges,,,420.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,792,,,percent of total billed charges,,,,,,,,,,,,,,,63.36,,,percent of total billed charges,,,792,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,792,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.65,,,percent of total billed charges,,
OXALIPLATIN 100 MG INJ,2500018943,CDM,636,RC,J9263,HCPCS,6170336250,NDC,,,,outpatient,facility,100,GR,792,792,0.07,792,,0.07,,,fee schedule,,,193.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,792,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,792,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,289.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.17,,,fee schedule,,,792,,,fee schedule,,,792,,,percent of total billed charges,,,,,,,,,792,,,percent of total billed charges,,,485.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,fee schedule,,,0.07,,,fee schedule,,,0.07,,,fee schedule,,,,,,,,,467.28,,,percent of total billed charges,,,548.68,,,per diem,,,792,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,792,,,percent of total billed charges,,,673.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,420.63,,,percent of total billed charges,,,792,,,percent of total billed charges,,,792,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.28,,,percent of total billed charges,,,640.89,,,percent of total billed charges,,,,,,,,,,,,,,,316.8,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,792,,,percent of total billed charges,,,792,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,792,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,63.36,,,percent of total billed charges,,,792,,,percent of total billed charges,,,,,,,,,,,,,,,792,,,percent of total billed charges,,,792,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.08,,,fee schedule,,,792,,,percent of total billed charges,,,792,,,percent of total billed charges,,,792,,,percent of total billed charges,,,,,,,,,555.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,396,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,466.65,,,percent of total billed charges,,
OXALIPLATIN 100 MG INJ,2500018943,CDM,636,RC,J9263,HCPCS,6170336250,NDC,435,EAPG,,outpatient,facility,100,GR,792,792,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OXALIPLATIN 50 MG INJ,2500018944,CDM,636,RC,J9263,HCPCS,1672933203,NDC,,,,inpatient,facility,50,GR,3501.13,3501.13,280.09,3501.13,,,,,,,,,,,,,,3501.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3501.13,,,percent of total billed charges,,,,,,,,,3501.13,,,percent of total billed charges,,,1787.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2981.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2100.68,,,percent of total billed charges,,,,,,,,,,,,,,,3501.13,,,percent of total billed charges,,,2975.96,,,percent of total billed charges,,,,,,,,,,,,,,,3501.13,,,percent of total billed charges,,,1859.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1400.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3501.13,,,percent of total billed charges,,,,,,,,,,,,,,,280.09,,,percent of total billed charges,,,3501.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3501.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2062.87,,,percent of total billed charges,,
OXALIPLATIN 50 MG INJ,2500018944,CDM,636,RC,J9263,HCPCS,1672933203,NDC,,,,outpatient,facility,50,GR,3501.13,3501.13,0.07,3501.13,,0.07,,,fee schedule,,,854.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3501.13,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,3501.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1281.41,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.17,,,fee schedule,,,3501.13,,,fee schedule,,,3501.13,,,percent of total billed charges,,,,,,,,,3501.13,,,percent of total billed charges,,,2145.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2494.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,fee schedule,,,0.07,,,fee schedule,,,0.07,,,fee schedule,,,,,,,,,2065.67,,,percent of total billed charges,,,548.68,,,per diem,,,3501.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3501.13,,,percent of total billed charges,,,2975.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1859.45,,,percent of total billed charges,,,3501.13,,,percent of total billed charges,,,3501.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2361.86,,,percent of total billed charges,,,2833.11,,,percent of total billed charges,,,,,,,,,,,,,,,1400.45,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3501.13,,,percent of total billed charges,,,3501.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3501.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,280.09,,,percent of total billed charges,,,3501.13,,,percent of total billed charges,,,,,,,,,,,,,,,3501.13,,,percent of total billed charges,,,3501.13,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.08,,,fee schedule,,,3501.13,,,percent of total billed charges,,,3501.13,,,percent of total billed charges,,,3501.13,,,percent of total billed charges,,,,,,,,,2454.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1750.57,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2062.87,,,percent of total billed charges,,
OXALIPLATIN 50 MG INJ,2500018944,CDM,636,RC,J9263,HCPCS,1672933203,NDC,435,EAPG,,outpatient,facility,50,GR,3501.13,3501.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESCITALOPRAM 10 MG TAB,2500018950,CDM,637,RC,904642661,NDC,,,,,,inpatient,facility,10,UN,14.45,14.45,1.16,14.45,,,,,,,,,,,,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.45,,,percent of total billed charges,,,,,,,,,14.45,,,percent of total billed charges,,,7.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.67,,,percent of total billed charges,,,,,,,,,,,,,,,14.45,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,14.45,,,percent of total billed charges,,,7.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.51,,,percent of total billed charges,,
ESCITALOPRAM 10 MG TAB,2500018950,CDM,637,RC,904642661,NDC,,,,,,outpatient,facility,10,UN,14.45,14.45,1.16,548.68,,10.25,,,percent of total billed charges,,,3.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.45,,,percent of total billed charges,,,9.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.45,,,fee schedule,,,14.45,,,percent of total billed charges,,,,,,,,,14.45,,,percent of total billed charges,,,8.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.3,,,percent of total billed charges,,,,,,,,,,,,,,,7.8,,,percent of total billed charges,,,7.51,,,percent of total billed charges,,,7.95,,,percent of total billed charges,,,,,,,,,8.53,,,percent of total billed charges,,,548.68,,,per diem,,,14.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.45,,,percent of total billed charges,,,12.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.67,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.75,,,percent of total billed charges,,,11.69,,,percent of total billed charges,,,,,,,,,,,,,,,5.78,,,percent of total billed charges,,,,,,,,,5.35,,,percent of total billed charges,,,5.35,,,percent of total billed charges,,,,,,,,,14.45,,,percent of total billed charges,,,14.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.16,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,14.45,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,,,,,,,13.44,,,percent of total billed charges,,,,,,,,,,,,,,,13.44,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,10.84,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,,,,,,,10.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.51,,,percent of total billed charges,,
ESCITALOPRAM 10 MG TAB,2500018950,CDM,637,RC,904642661,NDC,999,EAPG,,,,outpatient,facility,10,UN,14.45,14.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EZETIMIBE 10 MG TAB,2500019010,CDM,637,RC,6787749005,NDC,,,,,,inpatient,facility,10,UN,33.92,33.92,2.71,33.92,,,,,,,,,,,,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.92,,,percent of total billed charges,,,,,,,,,33.92,,,percent of total billed charges,,,17.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.35,,,percent of total billed charges,,,,,,,,,,,,,,,33.92,,,percent of total billed charges,,,28.83,,,percent of total billed charges,,,,,,,,,,,,,,,33.92,,,percent of total billed charges,,,18.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.99,,,percent of total billed charges,,
EZETIMIBE 10 MG TAB,2500019010,CDM,637,RC,6787749005,NDC,,,,,,outpatient,facility,10,UN,33.92,33.92,2.71,548.68,,24.05,,,percent of total billed charges,,,8.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,33.92,,,percent of total billed charges,,,21.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,23.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,23.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.41,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,33.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,33.92,,,fee schedule,,,33.92,,,percent of total billed charges,,,,,,,,,33.92,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.17,,,percent of total billed charges,,,,,,,,,,,,,,,18.32,,,percent of total billed charges,,,17.64,,,percent of total billed charges,,,18.66,,,percent of total billed charges,,,,,,,,,20.01,,,percent of total billed charges,,,548.68,,,per diem,,,33.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,33.92,,,percent of total billed charges,,,28.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.01,,,percent of total billed charges,,,33.92,,,percent of total billed charges,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.88,,,percent of total billed charges,,,27.45,,,percent of total billed charges,,,,,,,,,,,,,,,13.57,,,percent of total billed charges,,,,,,,,,12.55,,,percent of total billed charges,,,12.55,,,percent of total billed charges,,,,,,,,,33.92,,,percent of total billed charges,,,33.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.71,,,percent of total billed charges,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,33.92,,,percent of total billed charges,,,33.92,,,percent of total billed charges,,,,,,,,,31.55,,,percent of total billed charges,,,,,,,,,,,,,,,31.55,,,percent of total billed charges,,,31.55,,,percent of total billed charges,,,31.55,,,percent of total billed charges,,,25.44,,,percent of total billed charges,,,33.92,,,percent of total billed charges,,,33.92,,,percent of total billed charges,,,33.92,,,percent of total billed charges,,,,,,,,,23.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,19.99,,,percent of total billed charges,,
EZETIMIBE 10 MG TAB,2500019010,CDM,637,RC,6787749005,NDC,999,EAPG,,,,outpatient,facility,10,UN,33.92,33.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSULIN HUMAN 70/30 1 UNIT INJ,2500019041,CDM,637,RC,J1815,HCPCS,2871501,NDC,,,,inpatient,facility,0.01,UN,0.8,0.8,0.06,0.8,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.8,,,percent of total billed charges,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,
INSULIN HUMAN 70/30 1 UNIT INJ,2500019041,CDM,637,RC,J1815,HCPCS,2871501,NDC,,,,outpatient,facility,0.01,UN,0.8,0.8,0.06,548.68,,0.57,,,percent of total billed charges,,,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.8,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.8,,,fee schedule,,,0.8,,,percent of total billed charges,,,,,,,,,0.8,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,0.47,,,percent of total billed charges,,,548.68,,,per diem,,,0.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.8,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,0.8,,,percent of total billed charges,,,0.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.8,,,fee schedule,,,0.8,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.47,,,percent of total billed charges,,
INSULIN HUMAN 70/30 1 UNIT INJ,2500019041,CDM,637,RC,J1815,HCPCS,2871501,NDC,496,EAPG,,outpatient,facility,0.01,UN,0.8,0.8,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSULIN HUMAN REG 1 UNIT INJ,2500019042,CDM,637,RC,J1815,HCPCS,2821501,NDC,,,,inpatient,facility,0.01,UN,0.13,0.13,0.01,0.13,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,0.13,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,0.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,
INSULIN HUMAN REG 1 UNIT INJ,2500019042,CDM,637,RC,J1815,HCPCS,2821501,NDC,,,,outpatient,facility,0.01,UN,0.13,0.13,0.01,548.68,,0.09,,,percent of total billed charges,,,0.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.13,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.13,,,fee schedule,,,0.13,,,percent of total billed charges,,,,,,,,,0.13,,,percent of total billed charges,,,0.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,0.08,,,percent of total billed charges,,,548.68,,,per diem,,,0.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.13,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,0.11,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,0.13,,,percent of total billed charges,,,0.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,,0.13,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.13,,,fee schedule,,,0.13,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,0.13,,,percent of total billed charges,,,,,,,,,0.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.08,,,percent of total billed charges,,
INSULIN HUMAN REG 1 UNIT INJ,2500019042,CDM,637,RC,J1815,HCPCS,2821501,NDC,496,EAPG,,outpatient,facility,0.01,UN,0.13,0.13,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BORTEZOMIB 3.5 MG INJ,2500019080,CDM,636,RC,J9041,HCPCS,6302004901,NDC,,,,inpatient,facility,3.5,GR,5289.9,5289.9,423.19,5289.9,,,,,,,,,,,,,,5289.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5289.9,,,percent of total billed charges,,,,,,,,,5289.9,,,percent of total billed charges,,,2701.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4505.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3173.94,,,percent of total billed charges,,,,,,,,,,,,,,,5289.9,,,percent of total billed charges,,,4496.42,,,percent of total billed charges,,,,,,,,,,,,,,,5289.9,,,percent of total billed charges,,,2809.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2115.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5289.9,,,percent of total billed charges,,,,,,,,,,,,,,,423.19,,,percent of total billed charges,,,5289.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5289.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3116.81,,,percent of total billed charges,,
BORTEZOMIB 3.5 MG INJ,2500019080,CDM,636,RC,J9041,HCPCS,6302004901,NDC,,,,outpatient,facility,3.5,GR,5289.9,5289.9,1.79,5289.9,,2.07,,,fee schedule,,,1290.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5289.9,,,percent of total billed charges,,,2.25,,,fee schedule,,,2.12,,,fee schedule,,,,,,,,,2.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,5289.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1936.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,47.25,,,fee schedule,,,5289.9,,,fee schedule,,,5289.9,,,percent of total billed charges,,,,,,,,,5289.9,,,percent of total billed charges,,,3242.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3769.05,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,fee schedule,,,1.96,,,fee schedule,,,1.96,,,fee schedule,,,,,,,,,3121.04,,,percent of total billed charges,,,548.68,,,per diem,,,5289.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5289.9,,,percent of total billed charges,,,4496.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2809.47,,,percent of total billed charges,,,5289.9,,,percent of total billed charges,,,5289.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3568.57,,,percent of total billed charges,,,4280.59,,,percent of total billed charges,,,,,,,,,,,,,,,2115.96,,,percent of total billed charges,,,,,,,,,60.59,,,fee schedule,,,43.6,,,fee schedule,,,,,,,,,5289.9,,,percent of total billed charges,,,5289.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5289.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,423.19,,,percent of total billed charges,,,5289.9,,,percent of total billed charges,,,,,,,,,,,,,,,5289.9,,,percent of total billed charges,,,5289.9,,,percent of total billed charges,,,,,,,,,25.89,,,fee schedule,,,,,,,,,,,,,,,22.44,,,fee schedule,,,29.92,,,fee schedule,,,16.83,,,fee schedule,,,1.79,,,fee schedule,,,5289.9,,,percent of total billed charges,,,5289.9,,,percent of total billed charges,,,5289.9,,,percent of total billed charges,,,,,,,,,3708.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2644.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3116.81,,,percent of total billed charges,,
BORTEZOMIB 3.5 MG INJ,2500019080,CDM,636,RC,J9041,HCPCS,6302004901,NDC,433,EAPG,,outpatient,facility,3.5,GR,5289.9,5289.9,349.48,527.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,527.71,,,fee schedule,,,349.48,,,fee schedule,,,469.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.48,,,fee schedule,,,349.48,,,fee schedule,,,349.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,349.48,,,fee schedule,,,,,,,,,,,,,,,349.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSULIN HUMAN REG 100U/100ML,2500019104,CDM,637,RC,J1815,HCPCS,2821501,NDC,,,,inpatient,facility,100,UN,45.44,45.44,3.64,45.44,,,,,,,,,,,,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.44,,,percent of total billed charges,,,,,,,,,45.44,,,percent of total billed charges,,,23.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.26,,,percent of total billed charges,,,,,,,,,,,,,,,45.44,,,percent of total billed charges,,,38.62,,,percent of total billed charges,,,,,,,,,,,,,,,45.44,,,percent of total billed charges,,,24.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,3.64,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.77,,,percent of total billed charges,,
INSULIN HUMAN REG 100U/100ML,2500019104,CDM,637,RC,J1815,HCPCS,2821501,NDC,,,,outpatient,facility,100,UN,45.44,45.44,0.94,548.68,,32.22,,,percent of total billed charges,,,11.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,45.44,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,16.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,45.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,45.44,,,fee schedule,,,45.44,,,percent of total billed charges,,,,,,,,,45.44,,,percent of total billed charges,,,27.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,26.81,,,percent of total billed charges,,,548.68,,,per diem,,,45.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,45.44,,,percent of total billed charges,,,38.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.13,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.65,,,percent of total billed charges,,,36.77,,,percent of total billed charges,,,,,,,,,,,,,,,18.18,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,45.44,,,percent of total billed charges,,,45.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,45.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.64,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,,45.44,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.94,,,fee schedule,,,45.44,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,45.44,,,percent of total billed charges,,,,,,,,,31.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,26.77,,,percent of total billed charges,,
INSULIN HUMAN REG 100U/100ML,2500019104,CDM,637,RC,J1815,HCPCS,2821501,NDC,496,EAPG,,outpatient,facility,100,UN,45.44,45.44,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.45  1000 ML,2500019150,CDM,258,RC,J7040,HCPCS,264780200,NDC,,,,inpatient,facility,1000,UN,12.87,12.87,1.03,12.87,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,,,,,,,12.87,,,percent of total billed charges,,,6.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,10.94,,,percent of total billed charges,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,6.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.58,,,percent of total billed charges,,
SOD CHLORIDE 0.45  1000 ML,2500019150,CDM,258,RC,J7040,HCPCS,264780200,NDC,,,,outpatient,facility,1000,UN,12.87,12.87,1.03,548.68,,9.13,,,percent of total billed charges,,,3.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,12.87,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,12.87,,,fee schedule,,,12.87,,,percent of total billed charges,,,,,,,,,12.87,,,percent of total billed charges,,,7.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.59,,,percent of total billed charges,,,548.68,,,per diem,,,12.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12.87,,,percent of total billed charges,,,10.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.84,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.68,,,percent of total billed charges,,,10.41,,,percent of total billed charges,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,12.87,,,percent of total billed charges,,,12.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,12.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.03,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.4,,,fee schedule,,,12.87,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,,,,,,,9.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.58,,,percent of total billed charges,,
SOD CHLORIDE 0.45  1000 ML,2500019150,CDM,258,RC,J7040,HCPCS,264780200,NDC,496,EAPG,,outpatient,facility,1000,UN,12.87,12.87,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHL 0.45 KCL 20MEQ 1000ML,2500019151,CDM,636,RC,J3480,HCPCS,338070434,NDC,,,,inpatient,facility,1000,UN,23.83,23.83,1.91,23.83,,,,,,,,,,,,,,23.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,percent of total billed charges,,,,,,,,,23.83,,,percent of total billed charges,,,12.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.3,,,percent of total billed charges,,,,,,,,,,,,,,,23.83,,,percent of total billed charges,,,20.26,,,percent of total billed charges,,,,,,,,,,,,,,,23.83,,,percent of total billed charges,,,12.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,percent of total billed charges,,,,,,,,,,,,,,,1.91,,,percent of total billed charges,,,23.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.04,,,percent of total billed charges,,
SOD CHL 0.45 KCL 20MEQ 1000ML,2500019151,CDM,636,RC,J3480,HCPCS,338070434,NDC,,,,outpatient,facility,1000,UN,23.83,23.83,0.11,548.68,,16.9,,,percent of total billed charges,,,5.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,23.83,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,23.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.72,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,23.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,23.83,,,fee schedule,,,23.83,,,percent of total billed charges,,,,,,,,,23.83,,,percent of total billed charges,,,14.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,14.06,,,percent of total billed charges,,,548.68,,,per diem,,,23.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,23.83,,,percent of total billed charges,,,20.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.66,,,percent of total billed charges,,,23.83,,,percent of total billed charges,,,23.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.08,,,percent of total billed charges,,,19.28,,,percent of total billed charges,,,,,,,,,,,,,,,9.53,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,23.83,,,percent of total billed charges,,,23.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.91,,,percent of total billed charges,,,23.83,,,percent of total billed charges,,,,,,,,,,,,,,,23.83,,,percent of total billed charges,,,23.83,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,23.83,,,percent of total billed charges,,,23.83,,,percent of total billed charges,,,23.83,,,percent of total billed charges,,,,,,,,,16.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.04,,,percent of total billed charges,,
SOD CHL 0.45 KCL 20MEQ 1000ML,2500019151,CDM,636,RC,J3480,HCPCS,338070434,NDC,999,EAPG,,outpatient,facility,1000,UN,23.83,23.83,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.45 500 ML,2500019152,CDM,258,RC,J3490,HCPCS,338004303,NDC,,,,inpatient,facility,500,UN,15.54,15.54,1.24,15.54,,,,,,,,,,,,,,15.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.54,,,percent of total billed charges,,,,,,,,,15.54,,,percent of total billed charges,,,7.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.32,,,percent of total billed charges,,,,,,,,,,,,,,,15.54,,,percent of total billed charges,,,13.21,,,percent of total billed charges,,,,,,,,,,,,,,,15.54,,,percent of total billed charges,,,8.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,15.54,,,percent of total billed charges,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,15.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,
SOD CHLORIDE 0.45 500 ML,2500019152,CDM,258,RC,J3490,HCPCS,338004303,NDC,,,,outpatient,facility,500,UN,15.54,15.54,1.2,548.68,,11.02,,,percent of total billed charges,,,3.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,15.54,,,percent of total billed charges,,,9.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.92,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,15.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.69,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,15.54,,,fee schedule,,,15.54,,,percent of total billed charges,,,,,,,,,15.54,,,percent of total billed charges,,,9.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.07,,,percent of total billed charges,,,,,,,,,,,,,,,15.54,,,percent of total billed charges,,,15.54,,,percent of total billed charges,,,15.54,,,percent of total billed charges,,,,,,,,,9.17,,,percent of total billed charges,,,548.68,,,per diem,,,15.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,15.54,,,percent of total billed charges,,,13.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.25,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.48,,,percent of total billed charges,,,12.57,,,percent of total billed charges,,,,,,,,,,,,,,,6.22,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,15.54,,,percent of total billed charges,,,15.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.24,,,percent of total billed charges,,,15.54,,,percent of total billed charges,,,,,,,,,,,,,,,15.54,,,percent of total billed charges,,,15.54,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,11.65,,,percent of total billed charges,,,15.54,,,percent of total billed charges,,,15.54,,,percent of total billed charges,,,15.54,,,percent of total billed charges,,,,,,,,,10.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.16,,,percent of total billed charges,,
SOD CHLORIDE 0.45 500 ML,2500019152,CDM,258,RC,J3490,HCPCS,338004303,NDC,435,EAPG,,outpatient,facility,500,UN,15.54,15.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PALONOSETRON 0.25 MG,2500019200,CDM,636,RC,J2469,HCPCS,5515018605,NDC,,,,inpatient,facility,5,UN,79.2,79.2,6.34,79.2,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,,,,,,,79.2,,,percent of total billed charges,,,40.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.52,,,percent of total billed charges,,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,42.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,,,,,,,,,,,,,6.34,,,percent of total billed charges,,,79.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.66,,,percent of total billed charges,,
PALONOSETRON 0.25 MG,2500019200,CDM,636,RC,J2469,HCPCS,5515018605,NDC,,,,outpatient,facility,5,UN,79.2,79.2,0.85,548.68,,56.16,,,percent of total billed charges,,,19.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,79.2,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,28.99,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,20.36,,,fee schedule,,,79.2,,,fee schedule,,,79.2,,,percent of total billed charges,,,,,,,,,79.2,,,percent of total billed charges,,,48.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,fee schedule,,,0.85,,,fee schedule,,,0.85,,,fee schedule,,,,,,,,,46.73,,,percent of total billed charges,,,548.68,,,per diem,,,79.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,79.2,,,percent of total billed charges,,,67.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,42.06,,,percent of total billed charges,,,79.2,,,percent of total billed charges,,,79.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.43,,,percent of total billed charges,,,64.09,,,percent of total billed charges,,,,,,,,,,,,,,,31.68,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,79.2,,,percent of total billed charges,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.34,,,percent of total billed charges,,,79.2,,,percent of total billed charges,,,,,,,,,,,,,,,79.2,,,percent of total billed charges,,,79.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.01,,,fee schedule,,,79.2,,,percent of total billed charges,,,79.2,,,percent of total billed charges,,,79.2,,,percent of total billed charges,,,,,,,,,55.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,46.66,,,percent of total billed charges,,
PALONOSETRON 0.25 MG,2500019200,CDM,636,RC,J2469,HCPCS,5515018605,NDC,496,EAPG,,outpatient,facility,5,UN,79.2,79.2,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 2  20 ML INJ,2500019220,CDM,250,RC,J2003,HCPCS,5515025520,NDC,,,,inpatient,facility,20,UN,16.63,16.63,1.33,16.63,,,,,,,,,,,,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.63,,,percent of total billed charges,,,,,,,,,16.63,,,percent of total billed charges,,,8.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.98,,,percent of total billed charges,,,,,,,,,,,,,,,16.63,,,percent of total billed charges,,,14.14,,,percent of total billed charges,,,,,,,,,,,,,,,16.63,,,percent of total billed charges,,,8.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.8,,,percent of total billed charges,,
LIDOCAINE HCL 2  20 ML INJ,2500019220,CDM,250,RC,J2003,HCPCS,5515025520,NDC,,,,outpatient,facility,20,UN,16.63,16.63,1.33,548.68,,11.79,,,percent of total billed charges,,,4.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,16.63,,,percent of total billed charges,,,10.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,11.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,11.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.09,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,16.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,16.63,,,fee schedule,,,16.63,,,percent of total billed charges,,,,,,,,,16.63,,,percent of total billed charges,,,10.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,9.81,,,percent of total billed charges,,,548.68,,,per diem,,,16.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,16.63,,,percent of total billed charges,,,14.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.83,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.22,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,,,,,,,,,,,,,6.65,,,percent of total billed charges,,,,,,,,,6.15,,,percent of total billed charges,,,6.15,,,percent of total billed charges,,,,,,,,,16.63,,,percent of total billed charges,,,16.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.33,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,16.63,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,,,,,,,15.47,,,percent of total billed charges,,,,,,,,,,,,,,,15.47,,,percent of total billed charges,,,15.47,,,percent of total billed charges,,,15.47,,,percent of total billed charges,,,12.47,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,,,,,,,11.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.8,,,percent of total billed charges,,
LIDOCAINE HCL 2  20 ML INJ,2500019220,CDM,250,RC,J2003,HCPCS,5515025520,NDC,999,EAPG,,outpatient,facility,20,UN,16.63,16.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RISPERIDONE 25 MG/2ML INJ KIT,2500019233,CDM,636,RC,J2794,HCPCS,5045830611,NDC,,,,inpatient,facility,25,UN,1935.15,1935.15,154.81,1935.15,,,,,,,,,,,,,,1935.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1935.15,,,percent of total billed charges,,,,,,,,,1935.15,,,percent of total billed charges,,,988.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1648.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.09,,,percent of total billed charges,,,,,,,,,,,,,,,1935.15,,,percent of total billed charges,,,1644.88,,,percent of total billed charges,,,,,,,,,,,,,,,1935.15,,,percent of total billed charges,,,1027.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,774.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1935.15,,,percent of total billed charges,,,,,,,,,,,,,,,154.81,,,percent of total billed charges,,,1935.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1935.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1140.19,,,percent of total billed charges,,
RISPERIDONE 25 MG/2ML INJ KIT,2500019233,CDM,636,RC,J2794,HCPCS,5045830611,NDC,,,,outpatient,facility,25,UN,1935.15,1935.15,5.88,1935.15,,1372.21,,,percent of total billed charges,,,,,,,,,1935.15,,,percent of total billed charges,,,15.78,,,fee schedule,,,14.93,,,fee schedule,,,,,,,,,14.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1935.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.88,,,fee schedule,,,1935.15,,,fee schedule,,,1935.15,,,percent of total billed charges,,,,,,,,,1935.15,,,percent of total billed charges,,,1186.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1378.79,,,percent of total billed charges,,,,,,,,,,,,,,,12.15,,,fee schedule,,,12.15,,,fee schedule,,,12.15,,,fee schedule,,,,,,,,,1141.74,,,percent of total billed charges,,,548.68,,,per diem,,,1935.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1935.15,,,percent of total billed charges,,,1644.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1027.76,,,percent of total billed charges,,,1935.15,,,percent of total billed charges,,,1935.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1305.45,,,percent of total billed charges,,,1565.92,,,percent of total billed charges,,,,,,,,,,,,,,,774.06,,,percent of total billed charges,,,,,,,,,28.48,,,fee schedule,,,20.49,,,fee schedule,,,,,,,,,1935.15,,,percent of total billed charges,,,,,,,,,,,,,,,154.81,,,percent of total billed charges,,,1935.15,,,percent of total billed charges,,,,,,,,,,,,,,,1935.15,,,percent of total billed charges,,,1935.15,,,percent of total billed charges,,,,,,,,,12.17,,,fee schedule,,,,,,,,,,,,,,,10.55,,,fee schedule,,,14.06,,,fee schedule,,,7.91,,,fee schedule,,,12.63,,,fee schedule,,,1935.15,,,percent of total billed charges,,,1935.15,,,percent of total billed charges,,,1935.15,,,percent of total billed charges,,,,,,,,,1356.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,967.58,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1140.19,,,percent of total billed charges,,
RISPERIDONE 25 MG/2ML INJ KIT,2500019233,CDM,636,RC,J2794,HCPCS,5045830611,NDC,9125,APC,,outpatient,facility,25,UN,1935.15,1935.15,10.55,708.26,,,,,,,,11.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.1,,,fee schedule,,,,,,,,,708.26,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,,,,,,,11.54,,,fee schedule,,,11.54,,,fee schedule,,,,,,,,,10.99,,,fee schedule,,,10.99,,,fee schedule,,,11.54,,,fee schedule,,,,,,,,,,,,,,,16.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.55,,,fee schedule,,,11.76,,,fee schedule,,,11.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,10.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,13.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,10.99,,,fee schedule,,,10.99,,,fee schedule,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,10.99,,,fee schedule,,,11.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,,,,,,,11.43,,,fee schedule,,,10.99,,,fee schedule,,,,,,,,,10.99,,,fee schedule,,,,,,,,,10.99,,,fee schedule,,,11.54,,,fee schedule,,,,,,,,
RISPERIDONE 25 MG/2ML INJ KIT,2500019233,CDM,636,RC,J2794,HCPCS,5045830611,NDC,439,EAPG,,outpatient,facility,25,UN,1935.15,1935.15,790.67,1193.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1193.91,,,fee schedule,,,790.67,,,fee schedule,,,1061.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.67,,,fee schedule,,,790.67,,,fee schedule,,,790.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,790.67,,,fee schedule,,,,,,,,,,,,,,,790.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RISPERIDONE 37.5MG/2ML INJ KIT,2500019234,CDM,636,RC,J2794,HCPCS,5045830711,NDC,,,,inpatient,facility,37.5,UN,2902.88,2902.88,232.23,2902.88,,,,,,,,,,,,,,2902.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2902.88,,,percent of total billed charges,,,,,,,,,2902.88,,,percent of total billed charges,,,1482.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2472.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1741.73,,,percent of total billed charges,,,,,,,,,,,,,,,2902.88,,,percent of total billed charges,,,2467.45,,,percent of total billed charges,,,,,,,,,,,,,,,2902.88,,,percent of total billed charges,,,1541.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1161.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2902.88,,,percent of total billed charges,,,,,,,,,,,,,,,232.23,,,percent of total billed charges,,,2902.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2902.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1710.38,,,percent of total billed charges,,
RISPERIDONE 37.5MG/2ML INJ KIT,2500019234,CDM,636,RC,J2794,HCPCS,5045830711,NDC,,,,outpatient,facility,37.5,UN,2902.88,2902.88,5.88,2902.88,,2058.43,,,percent of total billed charges,,,,,,,,,2902.88,,,percent of total billed charges,,,15.78,,,fee schedule,,,14.93,,,fee schedule,,,,,,,,,14.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2902.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.88,,,fee schedule,,,2902.88,,,fee schedule,,,2902.88,,,percent of total billed charges,,,,,,,,,2902.88,,,percent of total billed charges,,,1779.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2068.3,,,percent of total billed charges,,,,,,,,,,,,,,,12.15,,,fee schedule,,,12.15,,,fee schedule,,,12.15,,,fee schedule,,,,,,,,,1712.7,,,percent of total billed charges,,,548.68,,,per diem,,,2902.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2902.88,,,percent of total billed charges,,,2467.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1541.72,,,percent of total billed charges,,,2902.88,,,percent of total billed charges,,,2902.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1958.28,,,percent of total billed charges,,,2349.01,,,percent of total billed charges,,,,,,,,,,,,,,,1161.15,,,percent of total billed charges,,,,,,,,,28.48,,,fee schedule,,,20.49,,,fee schedule,,,,,,,,,2902.88,,,percent of total billed charges,,,,,,,,,,,,,,,232.23,,,percent of total billed charges,,,2902.88,,,percent of total billed charges,,,,,,,,,,,,,,,2902.88,,,percent of total billed charges,,,2902.88,,,percent of total billed charges,,,,,,,,,12.17,,,fee schedule,,,,,,,,,,,,,,,10.55,,,fee schedule,,,14.06,,,fee schedule,,,7.91,,,fee schedule,,,12.63,,,fee schedule,,,2902.88,,,percent of total billed charges,,,2902.88,,,percent of total billed charges,,,2902.88,,,percent of total billed charges,,,,,,,,,2035.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1451.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1710.38,,,percent of total billed charges,,
RISPERIDONE 37.5MG/2ML INJ KIT,2500019234,CDM,636,RC,J2794,HCPCS,5045830711,NDC,9125,APC,,outpatient,facility,37.5,UN,2902.88,2902.88,10.55,1062.45,,,,,,,,11.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.1,,,fee schedule,,,,,,,,,1062.45,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,,,,,,,11.54,,,fee schedule,,,11.54,,,fee schedule,,,,,,,,,10.99,,,fee schedule,,,10.99,,,fee schedule,,,11.54,,,fee schedule,,,,,,,,,,,,,,,16.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.55,,,fee schedule,,,11.76,,,fee schedule,,,11.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,10.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,13.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,10.99,,,fee schedule,,,10.99,,,fee schedule,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,10.99,,,fee schedule,,,11.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.99,,,fee schedule,,,,,,,,,,,,,,,11.43,,,fee schedule,,,10.99,,,fee schedule,,,,,,,,,10.99,,,fee schedule,,,,,,,,,10.99,,,fee schedule,,,11.54,,,fee schedule,,,,,,,,
RISPERIDONE 37.5MG/2ML INJ KIT,2500019234,CDM,636,RC,J2794,HCPCS,5045830711,NDC,439,EAPG,,outpatient,facility,37.5,UN,2902.88,2902.88,790.67,1193.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1193.91,,,fee schedule,,,790.67,,,fee schedule,,,1061.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.67,,,fee schedule,,,790.67,,,fee schedule,,,790.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,790.67,,,fee schedule,,,,,,,,,,,,,,,790.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RISPERIDONE ODT 0.5 MG,2500019236,CDM,637,RC,5974601032,NDC,,,,,,inpatient,facility,0.5,UN,16.24,16.24,1.3,16.24,,,,,,,,,,,,,,16.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.24,,,percent of total billed charges,,,,,,,,,16.24,,,percent of total billed charges,,,8.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.74,,,percent of total billed charges,,,,,,,,,,,,,,,16.24,,,percent of total billed charges,,,13.8,,,percent of total billed charges,,,,,,,,,,,,,,,16.24,,,percent of total billed charges,,,8.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,16.24,,,percent of total billed charges,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,16.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.57,,,percent of total billed charges,,
RISPERIDONE ODT 0.5 MG,2500019236,CDM,637,RC,5974601032,NDC,,,,,,outpatient,facility,0.5,UN,16.24,16.24,1.3,548.68,,11.52,,,percent of total billed charges,,,3.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,16.24,,,percent of total billed charges,,,10.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,11.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,11.42,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,16.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.94,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,16.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,16.24,,,fee schedule,,,16.24,,,percent of total billed charges,,,,,,,,,16.24,,,percent of total billed charges,,,9.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.57,,,percent of total billed charges,,,,,,,,,,,,,,,8.77,,,percent of total billed charges,,,8.44,,,percent of total billed charges,,,8.93,,,percent of total billed charges,,,,,,,,,9.58,,,percent of total billed charges,,,548.68,,,per diem,,,16.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,16.24,,,percent of total billed charges,,,13.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.63,,,percent of total billed charges,,,16.24,,,percent of total billed charges,,,16.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.96,,,percent of total billed charges,,,13.14,,,percent of total billed charges,,,,,,,,,,,,,,,6.5,,,percent of total billed charges,,,,,,,,,6.01,,,percent of total billed charges,,,6.01,,,percent of total billed charges,,,,,,,,,16.24,,,percent of total billed charges,,,16.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.3,,,percent of total billed charges,,,16.24,,,percent of total billed charges,,,,,,,,,,,,,,,16.24,,,percent of total billed charges,,,16.24,,,percent of total billed charges,,,,,,,,,15.11,,,percent of total billed charges,,,,,,,,,,,,,,,15.11,,,percent of total billed charges,,,15.11,,,percent of total billed charges,,,15.11,,,percent of total billed charges,,,12.18,,,percent of total billed charges,,,16.24,,,percent of total billed charges,,,16.24,,,percent of total billed charges,,,16.24,,,percent of total billed charges,,,,,,,,,11.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.57,,,percent of total billed charges,,
RISPERIDONE ODT 0.5 MG,2500019236,CDM,637,RC,5974601032,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,16.24,16.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BCG LIVE PER INSTIL,2500019244,CDM,636,RC,J9030,HCPCS,52060202,NDC,,,,inpatient,facility,81,GR,539.06,539.06,43.12,539.06,,,,,,,,,,,,,,539.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,539.06,,,percent of total billed charges,,,,,,,,,539.06,,,percent of total billed charges,,,275.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,459.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.44,,,percent of total billed charges,,,,,,,,,,,,,,,539.06,,,percent of total billed charges,,,458.2,,,percent of total billed charges,,,,,,,,,,,,,,,539.06,,,percent of total billed charges,,,286.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,539.06,,,percent of total billed charges,,,,,,,,,,,,,,,43.12,,,percent of total billed charges,,,539.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,539.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,317.61,,,percent of total billed charges,,
BCG LIVE PER INSTIL,2500019244,CDM,636,RC,J9030,HCPCS,52060202,NDC,,,,outpatient,facility,81,GR,539.06,539.06,2.89,548.68,,2.89,,,fee schedule,,,131.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,539.06,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,539.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,197.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,539.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,539.06,,,fee schedule,,,539.06,,,percent of total billed charges,,,,,,,,,539.06,,,percent of total billed charges,,,330.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.89,,,fee schedule,,,2.89,,,fee schedule,,,2.89,,,fee schedule,,,,,,,,,318.05,,,percent of total billed charges,,,548.68,,,per diem,,,539.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,539.06,,,percent of total billed charges,,,458.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,286.29,,,percent of total billed charges,,,539.06,,,percent of total billed charges,,,539.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.65,,,percent of total billed charges,,,436.21,,,percent of total billed charges,,,,,,,,,,,,,,,215.62,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,539.06,,,percent of total billed charges,,,539.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,539.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.12,,,percent of total billed charges,,,539.06,,,percent of total billed charges,,,,,,,,,,,,,,,539.06,,,percent of total billed charges,,,539.06,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,2.98,,,fee schedule,,,539.06,,,percent of total billed charges,,,539.06,,,percent of total billed charges,,,539.06,,,percent of total billed charges,,,,,,,,,377.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,269.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,317.61,,,percent of total billed charges,,
BCG LIVE PER INSTIL,2500019244,CDM,636,RC,J9030,HCPCS,52060202,NDC,431,EAPG,,outpatient,facility,81,GR,539.06,539.06,42.81,64.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.64,,,fee schedule,,,42.81,,,fee schedule,,,57.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.81,,,fee schedule,,,42.81,,,fee schedule,,,42.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,42.81,,,fee schedule,,,,,,,,,,,,,,,42.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ETOPOSIDE  100MG/5ML,2500019253,CDM,636,RC,J9181,HCPCS,143951001,NDC,,,,inpatient,facility,5,GR,30.92,30.92,2.47,30.92,,,,,,,,,,,,,,30.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.92,,,percent of total billed charges,,,,,,,,,30.92,,,percent of total billed charges,,,15.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.55,,,percent of total billed charges,,,,,,,,,,,,,,,30.92,,,percent of total billed charges,,,26.28,,,percent of total billed charges,,,,,,,,,,,,,,,30.92,,,percent of total billed charges,,,16.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,30.92,,,percent of total billed charges,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,30.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.22,,,percent of total billed charges,,
ETOPOSIDE  100MG/5ML,2500019253,CDM,636,RC,J9181,HCPCS,143951001,NDC,,,,outpatient,facility,5,GR,30.92,30.92,1,548.68,,1.05,,,fee schedule,,,7.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,30.92,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,30.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.32,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1,,,fee schedule,,,30.92,,,fee schedule,,,30.92,,,percent of total billed charges,,,,,,,,,30.92,,,percent of total billed charges,,,18.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,18.24,,,percent of total billed charges,,,548.68,,,per diem,,,30.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,30.92,,,percent of total billed charges,,,26.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.42,,,percent of total billed charges,,,30.92,,,percent of total billed charges,,,30.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.86,,,percent of total billed charges,,,25.02,,,percent of total billed charges,,,,,,,,,,,,,,,12.37,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,30.92,,,percent of total billed charges,,,30.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.47,,,percent of total billed charges,,,30.92,,,percent of total billed charges,,,,,,,,,,,,,,,30.92,,,percent of total billed charges,,,30.92,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.18,,,fee schedule,,,30.92,,,percent of total billed charges,,,30.92,,,percent of total billed charges,,,30.92,,,percent of total billed charges,,,,,,,,,21.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.22,,,percent of total billed charges,,
ETOPOSIDE  100MG/5ML,2500019253,CDM,636,RC,J9181,HCPCS,143951001,NDC,495,EAPG,,outpatient,facility,5,GR,30.92,30.92,21.18,31.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.98,,,fee schedule,,,21.18,,,fee schedule,,,28.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,21.18,,,fee schedule,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DAPTOMYCIN 500 MG INJ,2500019281,CDM,636,RC,J0878,HCPCS,1671489201,NDC,,,,inpatient,facility,500,GR,214.6,214.6,17.17,214.6,,,,,,,,,,,,,,214.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.6,,,percent of total billed charges,,,,,,,,,214.6,,,percent of total billed charges,,,109.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.76,,,percent of total billed charges,,,,,,,,,,,,,,,214.6,,,percent of total billed charges,,,182.41,,,percent of total billed charges,,,,,,,,,,,,,,,214.6,,,percent of total billed charges,,,113.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,214.6,,,percent of total billed charges,,,,,,,,,,,,,,,17.17,,,percent of total billed charges,,,214.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,214.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.44,,,percent of total billed charges,,
DAPTOMYCIN 500 MG INJ,2500019281,CDM,636,RC,J0878,HCPCS,1671489201,NDC,,,,outpatient,facility,500,GR,214.6,214.6,0.02,548.68,,152.17,,,percent of total billed charges,,,52.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,214.6,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,214.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,78.54,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,214.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,214.6,,,fee schedule,,,214.6,,,percent of total billed charges,,,,,,,,,214.6,,,percent of total billed charges,,,131.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.9,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,fee schedule,,,0.04,,,fee schedule,,,0.04,,,fee schedule,,,,,,,,,126.61,,,percent of total billed charges,,,548.68,,,per diem,,,214.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,214.6,,,percent of total billed charges,,,182.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.97,,,percent of total billed charges,,,214.6,,,percent of total billed charges,,,214.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.77,,,percent of total billed charges,,,173.65,,,percent of total billed charges,,,,,,,,,,,,,,,85.84,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,214.6,,,percent of total billed charges,,,214.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,214.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.17,,,percent of total billed charges,,,214.6,,,percent of total billed charges,,,,,,,,,,,,,,,214.6,,,percent of total billed charges,,,214.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.02,,,fee schedule,,,214.6,,,percent of total billed charges,,,214.6,,,percent of total billed charges,,,214.6,,,percent of total billed charges,,,,,,,,,150.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,126.44,,,percent of total billed charges,,
DAPTOMYCIN 500 MG INJ,2500019281,CDM,636,RC,J0878,HCPCS,1671489201,NDC,435,EAPG,,outpatient,facility,500,GR,214.6,214.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MOXIFLOXACIN 0.5  OPH 3 ML,2500019285,CDM,637,RC,6586284003,NDC,,,,,,inpatient,facility,3,UN,552.26,552.26,44.18,552.26,,,,,,,,,,,,,,552.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,552.26,,,percent of total billed charges,,,,,,,,,552.26,,,percent of total billed charges,,,281.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,470.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.36,,,percent of total billed charges,,,,,,,,,,,,,,,552.26,,,percent of total billed charges,,,469.42,,,percent of total billed charges,,,,,,,,,,,,,,,552.26,,,percent of total billed charges,,,293.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,552.26,,,percent of total billed charges,,,,,,,,,,,,,,,44.18,,,percent of total billed charges,,,552.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.39,,,percent of total billed charges,,
MOXIFLOXACIN 0.5  OPH 3 ML,2500019285,CDM,637,RC,6586284003,NDC,,,,,,outpatient,facility,3,UN,552.26,552.26,44.18,552.26,,391.61,,,percent of total billed charges,,,134.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,552.26,,,percent of total billed charges,,,346.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,388.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,388.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,552.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,202.13,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,552.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,552.26,,,fee schedule,,,552.26,,,percent of total billed charges,,,,,,,,,552.26,,,percent of total billed charges,,,338.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,393.49,,,percent of total billed charges,,,,,,,,,,,,,,,298.22,,,percent of total billed charges,,,287.18,,,percent of total billed charges,,,303.74,,,percent of total billed charges,,,,,,,,,325.83,,,percent of total billed charges,,,548.68,,,per diem,,,552.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,552.26,,,percent of total billed charges,,,469.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,293.31,,,percent of total billed charges,,,552.26,,,percent of total billed charges,,,552.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.55,,,percent of total billed charges,,,446.89,,,percent of total billed charges,,,,,,,,,,,,,,,220.9,,,percent of total billed charges,,,,,,,,,204.34,,,percent of total billed charges,,,204.34,,,percent of total billed charges,,,,,,,,,552.26,,,percent of total billed charges,,,552.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,552.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,44.18,,,percent of total billed charges,,,552.26,,,percent of total billed charges,,,,,,,,,,,,,,,552.26,,,percent of total billed charges,,,552.26,,,percent of total billed charges,,,,,,,,,513.71,,,percent of total billed charges,,,,,,,,,,,,,,,513.71,,,percent of total billed charges,,,513.71,,,percent of total billed charges,,,513.71,,,percent of total billed charges,,,414.19,,,percent of total billed charges,,,552.26,,,percent of total billed charges,,,552.26,,,percent of total billed charges,,,552.26,,,percent of total billed charges,,,,,,,,,387.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,325.39,,,percent of total billed charges,,
MOXIFLOXACIN 0.5  OPH 3 ML,2500019285,CDM,637,RC,6586284003,NDC,999,EAPG,,,,outpatient,facility,3,UN,552.26,552.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEMANTINE HCL 5 MG TAB,2500019286,CDM,637,RC,591387044,NDC,,,,,,inpatient,facility,5,UN,20.13,20.13,1.61,20.13,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,,,,20.13,,,percent of total billed charges,,,10.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.08,,,percent of total billed charges,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,17.11,,,percent of total billed charges,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,10.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.86,,,percent of total billed charges,,
MEMANTINE HCL 5 MG TAB,2500019286,CDM,637,RC,591387044,NDC,,,,,,outpatient,facility,5,UN,20.13,20.13,1.61,548.68,,14.27,,,percent of total billed charges,,,4.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,20.13,,,percent of total billed charges,,,12.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,14.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,14.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.37,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,20.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,20.13,,,fee schedule,,,20.13,,,percent of total billed charges,,,,,,,,,20.13,,,percent of total billed charges,,,12.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.34,,,percent of total billed charges,,,,,,,,,,,,,,,10.87,,,percent of total billed charges,,,10.47,,,percent of total billed charges,,,11.07,,,percent of total billed charges,,,,,,,,,11.88,,,percent of total billed charges,,,548.68,,,per diem,,,20.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,20.13,,,percent of total billed charges,,,17.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.69,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.58,,,percent of total billed charges,,,16.29,,,percent of total billed charges,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,7.45,,,percent of total billed charges,,,7.45,,,percent of total billed charges,,,,,,,,,20.13,,,percent of total billed charges,,,20.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.61,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,,,,,,,18.72,,,percent of total billed charges,,,,,,,,,,,,,,,18.72,,,percent of total billed charges,,,18.72,,,percent of total billed charges,,,18.72,,,percent of total billed charges,,,15.1,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,,,,,,,14.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.86,,,percent of total billed charges,,
MEMANTINE HCL 5 MG TAB,2500019286,CDM,637,RC,591387044,NDC,999,EAPG,,,,outpatient,facility,5,UN,20.13,20.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BIVALIRUDIN INJ 250MG,2500019287,CDM,636,RC,J0583,HCPCS,1672927567,NDC,,,,inpatient,facility,250,UN,3752.99,3752.99,300.24,3752.99,,,,,,,,,,,,,,3752.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3752.99,,,percent of total billed charges,,,,,,,,,3752.99,,,percent of total billed charges,,,1916.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3196.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2251.79,,,percent of total billed charges,,,,,,,,,,,,,,,3752.99,,,percent of total billed charges,,,3190.04,,,percent of total billed charges,,,,,,,,,,,,,,,3752.99,,,percent of total billed charges,,,1993.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1501.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3752.99,,,percent of total billed charges,,,,,,,,,,,,,,,300.24,,,percent of total billed charges,,,3752.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3752.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2211.26,,,percent of total billed charges,,
BIVALIRUDIN INJ 250MG,2500019287,CDM,636,RC,J0583,HCPCS,1672927567,NDC,,,,outpatient,facility,250,UN,3752.99,3752.99,0.21,3752.99,,2661.25,,,percent of total billed charges,,,915.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3752.99,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,3752.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1373.59,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3752.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3752.99,,,fee schedule,,,3752.99,,,percent of total billed charges,,,,,,,,,3752.99,,,percent of total billed charges,,,2300.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2674.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.21,,,fee schedule,,,0.21,,,fee schedule,,,0.21,,,fee schedule,,,,,,,,,2214.26,,,percent of total billed charges,,,548.68,,,per diem,,,3752.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3752.99,,,percent of total billed charges,,,3190.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1993.21,,,percent of total billed charges,,,3752.99,,,percent of total billed charges,,,3752.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2531.77,,,percent of total billed charges,,,3036.92,,,percent of total billed charges,,,,,,,,,,,,,,,1501.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3752.99,,,percent of total billed charges,,,3752.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3752.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,300.24,,,percent of total billed charges,,,3752.99,,,percent of total billed charges,,,,,,,,,,,,,,,3752.99,,,percent of total billed charges,,,3752.99,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.21,,,fee schedule,,,3752.99,,,percent of total billed charges,,,3752.99,,,percent of total billed charges,,,3752.99,,,percent of total billed charges,,,,,,,,,2631.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2211.26,,,percent of total billed charges,,
BIVALIRUDIN INJ 250MG,2500019287,CDM,636,RC,J0583,HCPCS,1672927567,NDC,999,EAPG,,outpatient,facility,250,UN,3752.99,3752.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POLYETHLYENE GLYCOL 17 GM PWD,2500019288,CDM,637,RC,904693181,NDC,,,,,,inpatient,facility,17,UN,2.08,2.08,0.17,2.08,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,0.17,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.23,,,percent of total billed charges,,
POLYETHLYENE GLYCOL 17 GM PWD,2500019288,CDM,637,RC,904693181,NDC,,,,,,outpatient,facility,17,UN,2.08,2.08,0.17,548.68,,1.47,,,percent of total billed charges,,,0.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.08,,,percent of total billed charges,,,1.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.76,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.08,,,fee schedule,,,2.08,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,1.14,,,percent of total billed charges,,,,,,,,,1.23,,,percent of total billed charges,,,548.68,,,per diem,,,2.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.08,,,percent of total billed charges,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.4,,,percent of total billed charges,,,1.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,0.77,,,percent of total billed charges,,,0.77,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,2.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.17,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,1.56,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,1.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.23,,,percent of total billed charges,,
POLYETHLYENE GLYCOL 17 GM PWD,2500019288,CDM,637,RC,904693181,NDC,999,EAPG,,,,outpatient,facility,17,UN,2.08,2.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUTEROL 2.5 MG/0.5 ML,2500019289,CDM,637,RC,487990130,NDC,,,,,,inpatient,facility,0.5,UN,2.97,2.97,0.24,2.97,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,
ALBUTEROL 2.5 MG/0.5 ML,2500019289,CDM,637,RC,487990130,NDC,,,,,,outpatient,facility,0.5,UN,2.97,2.97,0.24,548.68,,2.11,,,percent of total billed charges,,,0.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.97,,,percent of total billed charges,,,1.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.09,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.97,,,fee schedule,,,2.97,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,548.68,,,per diem,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.97,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,2.76,,,percent of total billed charges,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.75,,,percent of total billed charges,,
ALBUTEROL 2.5 MG/0.5 ML,2500019289,CDM,637,RC,487990130,NDC,999,EAPG,,,,outpatient,facility,0.5,UN,2.97,2.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIVALPROEX 250MG (DEPAKOTE ER),2500019290,CDM,637,RC,904636345,NDC,,,,,,inpatient,facility,250,UN,5.02,5.02,0.4,5.02,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,,,,,,,5.02,,,percent of total billed charges,,,2.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.01,,,percent of total billed charges,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,4.27,,,percent of total billed charges,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,2.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.96,,,percent of total billed charges,,
DIVALPROEX 250MG (DEPAKOTE ER),2500019290,CDM,637,RC,904636345,NDC,,,,,,outpatient,facility,250,UN,5.02,5.02,0.4,548.68,,3.56,,,percent of total billed charges,,,1.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.02,,,percent of total billed charges,,,3.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.84,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.02,,,fee schedule,,,5.02,,,percent of total billed charges,,,,,,,,,5.02,,,percent of total billed charges,,,3.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,2.61,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,,,,,,,2.96,,,percent of total billed charges,,,548.68,,,per diem,,,5.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.02,,,percent of total billed charges,,,4.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,2.01,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,,,,,,,5.02,,,percent of total billed charges,,,5.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.4,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,,,,,,,,,,,,,5.02,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,,,,,,,4.67,,,percent of total billed charges,,,,,,,,,,,,,,,4.67,,,percent of total billed charges,,,4.67,,,percent of total billed charges,,,4.67,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,5.02,,,percent of total billed charges,,,,,,,,,3.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.96,,,percent of total billed charges,,
DIVALPROEX 250MG (DEPAKOTE ER),2500019290,CDM,637,RC,904636345,NDC,999,EAPG,,,,outpatient,facility,250,UN,5.02,5.02,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DIVALPROEX 500MG (DEPAKOTE ER),2500019291,CDM,637,RC,904636461,NDC,,,,,,inpatient,facility,500,UN,6.8,6.8,0.54,6.8,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,6.8,,,percent of total billed charges,,,3.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.08,,,percent of total billed charges,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,3.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.01,,,percent of total billed charges,,
DIVALPROEX 500MG (DEPAKOTE ER),2500019291,CDM,637,RC,904636461,NDC,,,,,,outpatient,facility,500,UN,6.8,6.8,0.54,548.68,,4.82,,,percent of total billed charges,,,1.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.8,,,percent of total billed charges,,,4.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.78,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.8,,,fee schedule,,,6.8,,,percent of total billed charges,,,,,,,,,6.8,,,percent of total billed charges,,,4.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.84,,,percent of total billed charges,,,,,,,,,,,,,,,3.67,,,percent of total billed charges,,,3.54,,,percent of total billed charges,,,3.74,,,percent of total billed charges,,,,,,,,,4.01,,,percent of total billed charges,,,548.68,,,per diem,,,6.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.8,,,percent of total billed charges,,,5.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.61,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,5.5,,,percent of total billed charges,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,,,,,,,,2.52,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,6.8,,,percent of total billed charges,,,6.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.54,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,6.33,,,percent of total billed charges,,,,,,,,,,,,,,,6.33,,,percent of total billed charges,,,6.33,,,percent of total billed charges,,,6.33,,,percent of total billed charges,,,5.1,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,,,,,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.01,,,percent of total billed charges,,
DIVALPROEX 500MG (DEPAKOTE ER),2500019291,CDM,637,RC,904636461,NDC,999,EAPG,,,,outpatient,facility,500,UN,6.8,6.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM CL 10MEQ/100 ML IV,2500019297,CDM,636,RC,J3480,HCPCS,338070948,NDC,,,,inpatient,facility,100,ML,13.04,13.04,1.04,13.04,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,,,,,,,13.04,,,percent of total billed charges,,,6.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.82,,,percent of total billed charges,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,11.08,,,percent of total billed charges,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,6.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.68,,,percent of total billed charges,,
POTASSIUM CL 10MEQ/100 ML IV,2500019297,CDM,636,RC,J3480,HCPCS,338070948,NDC,,,,outpatient,facility,100,ML,13.04,13.04,0.11,548.68,,9.25,,,percent of total billed charges,,,3.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.04,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.77,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.04,,,fee schedule,,,13.04,,,percent of total billed charges,,,,,,,,,13.04,,,percent of total billed charges,,,7.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,7.69,,,percent of total billed charges,,,548.68,,,per diem,,,13.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.04,,,percent of total billed charges,,,11.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.93,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.8,,,percent of total billed charges,,,10.55,,,percent of total billed charges,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,13.04,,,percent of total billed charges,,,13.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.04,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,13.04,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,,,,,,,9.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7.68,,,percent of total billed charges,,
POTASSIUM CL 10MEQ/100 ML IV,2500019297,CDM,636,RC,J3480,HCPCS,338070948,NDC,999,EAPG,,outpatient,facility,100,ML,13.04,13.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEVONORGESTREL 1.5 MG TAB,2500019303,CDM,637,RC,6818085211,NDC,,,,,,inpatient,facility,1.5,UN,54.84,54.84,4.39,54.84,,,,,,,,,,,,,,54.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.84,,,percent of total billed charges,,,,,,,,,54.84,,,percent of total billed charges,,,28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.9,,,percent of total billed charges,,,,,,,,,,,,,,,54.84,,,percent of total billed charges,,,46.61,,,percent of total billed charges,,,,,,,,,,,,,,,54.84,,,percent of total billed charges,,,29.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,54.84,,,percent of total billed charges,,,,,,,,,,,,,,,4.39,,,percent of total billed charges,,,54.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.31,,,percent of total billed charges,,
LEVONORGESTREL 1.5 MG TAB,2500019303,CDM,637,RC,6818085211,NDC,,,,,,outpatient,facility,1.5,UN,54.84,54.84,4.39,548.68,,38.89,,,percent of total billed charges,,,13.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,54.84,,,percent of total billed charges,,,34.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,38.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,38.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,54.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,20.07,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,54.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,54.84,,,fee schedule,,,54.84,,,percent of total billed charges,,,,,,,,,54.84,,,percent of total billed charges,,,33.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.07,,,percent of total billed charges,,,,,,,,,,,,,,,29.61,,,percent of total billed charges,,,28.52,,,percent of total billed charges,,,30.16,,,percent of total billed charges,,,,,,,,,32.36,,,percent of total billed charges,,,548.68,,,per diem,,,54.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,54.84,,,percent of total billed charges,,,46.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.13,,,percent of total billed charges,,,54.84,,,percent of total billed charges,,,54.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37,,,percent of total billed charges,,,44.38,,,percent of total billed charges,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,20.29,,,percent of total billed charges,,,20.29,,,percent of total billed charges,,,,,,,,,54.84,,,percent of total billed charges,,,54.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,54.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.39,,,percent of total billed charges,,,54.84,,,percent of total billed charges,,,,,,,,,,,,,,,54.84,,,percent of total billed charges,,,54.84,,,percent of total billed charges,,,,,,,,,51.01,,,percent of total billed charges,,,,,,,,,,,,,,,51.01,,,percent of total billed charges,,,51.01,,,percent of total billed charges,,,51.01,,,percent of total billed charges,,,41.13,,,percent of total billed charges,,,54.84,,,percent of total billed charges,,,54.84,,,percent of total billed charges,,,54.84,,,percent of total billed charges,,,,,,,,,38.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,32.31,,,percent of total billed charges,,
LEVONORGESTREL 1.5 MG TAB,2500019303,CDM,637,RC,6818085211,NDC,999,EAPG,,,,outpatient,facility,1.5,UN,54.84,54.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATOMOXETINE HCL 40MG CAP,2500019320,CDM,637,RC,6846226830,NDC,,,,,,inpatient,facility,40,UN,51.05,51.05,4.08,51.05,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,,,,,,,51.05,,,percent of total billed charges,,,26.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.63,,,percent of total billed charges,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,43.39,,,percent of total billed charges,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,27.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,4.08,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.08,,,percent of total billed charges,,
ATOMOXETINE HCL 40MG CAP,2500019320,CDM,637,RC,6846226830,NDC,,,,,,outpatient,facility,40,UN,51.05,51.05,4.08,548.68,,36.2,,,percent of total billed charges,,,12.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,51.05,,,percent of total billed charges,,,31.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,35.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,35.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,18.68,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,51.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,51.05,,,fee schedule,,,51.05,,,percent of total billed charges,,,,,,,,,51.05,,,percent of total billed charges,,,31.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.37,,,percent of total billed charges,,,,,,,,,,,,,,,27.57,,,percent of total billed charges,,,26.55,,,percent of total billed charges,,,28.08,,,percent of total billed charges,,,,,,,,,30.12,,,percent of total billed charges,,,548.68,,,per diem,,,51.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,51.05,,,percent of total billed charges,,,43.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.11,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.44,,,percent of total billed charges,,,41.31,,,percent of total billed charges,,,,,,,,,,,,,,,20.42,,,percent of total billed charges,,,,,,,,,18.89,,,percent of total billed charges,,,18.89,,,percent of total billed charges,,,,,,,,,51.05,,,percent of total billed charges,,,51.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,51.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.08,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,,,,,,,,,,,,,51.05,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,,,,,,,47.49,,,percent of total billed charges,,,,,,,,,,,,,,,47.49,,,percent of total billed charges,,,47.49,,,percent of total billed charges,,,47.49,,,percent of total billed charges,,,38.29,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,51.05,,,percent of total billed charges,,,,,,,,,35.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,30.08,,,percent of total billed charges,,
ATOMOXETINE HCL 40MG CAP,2500019320,CDM,637,RC,6846226830,NDC,999,EAPG,,,,outpatient,facility,40,UN,51.05,51.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREDNISOLONE AC 0.12  OP 5 ML,2500019330,CDM,637,RC,1198017405,NDC,,,,,,inpatient,facility,5,UN,529.32,529.32,42.35,529.32,,,,,,,,,,,,,,529.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,529.32,,,percent of total billed charges,,,,,,,,,529.32,,,percent of total billed charges,,,270.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,450.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,317.59,,,percent of total billed charges,,,,,,,,,,,,,,,529.32,,,percent of total billed charges,,,449.92,,,percent of total billed charges,,,,,,,,,,,,,,,529.32,,,percent of total billed charges,,,281.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,529.32,,,percent of total billed charges,,,,,,,,,,,,,,,42.35,,,percent of total billed charges,,,529.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,529.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,311.88,,,percent of total billed charges,,
PREDNISOLONE AC 0.12  OP 5 ML,2500019330,CDM,637,RC,1198017405,NDC,,,,,,outpatient,facility,5,UN,529.32,529.32,42.35,548.68,,375.34,,,percent of total billed charges,,,129.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,529.32,,,percent of total billed charges,,,331.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,372.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,372.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,529.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,193.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,529.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,529.32,,,fee schedule,,,529.32,,,percent of total billed charges,,,,,,,,,529.32,,,percent of total billed charges,,,324.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.14,,,percent of total billed charges,,,,,,,,,,,,,,,285.83,,,percent of total billed charges,,,275.25,,,percent of total billed charges,,,291.13,,,percent of total billed charges,,,,,,,,,312.3,,,percent of total billed charges,,,548.68,,,per diem,,,529.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,529.32,,,percent of total billed charges,,,449.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,281.12,,,percent of total billed charges,,,529.32,,,percent of total billed charges,,,529.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.08,,,percent of total billed charges,,,428.33,,,percent of total billed charges,,,,,,,,,,,,,,,211.73,,,percent of total billed charges,,,,,,,,,195.85,,,percent of total billed charges,,,195.85,,,percent of total billed charges,,,,,,,,,529.32,,,percent of total billed charges,,,529.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,529.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,42.35,,,percent of total billed charges,,,529.32,,,percent of total billed charges,,,,,,,,,,,,,,,529.32,,,percent of total billed charges,,,529.32,,,percent of total billed charges,,,,,,,,,492.37,,,percent of total billed charges,,,,,,,,,,,,,,,492.37,,,percent of total billed charges,,,492.37,,,percent of total billed charges,,,492.37,,,percent of total billed charges,,,396.99,,,percent of total billed charges,,,529.32,,,percent of total billed charges,,,529.32,,,percent of total billed charges,,,529.32,,,percent of total billed charges,,,,,,,,,371.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,311.88,,,percent of total billed charges,,
PREDNISOLONE AC 0.12  OP 5 ML,2500019330,CDM,637,RC,1198017405,NDC,999,EAPG,,,,outpatient,facility,5,UN,529.32,529.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BEVACIZUMAB 100 MG/4 ML INJ,2500019341,CDM,636,RC,J9035,HCPCS,5024206001,NDC,,,,inpatient,facility,4,GR,2629.9,2629.9,210.39,2629.9,,,,,,,,,,,,,,2629.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2629.9,,,percent of total billed charges,,,,,,,,,2629.9,,,percent of total billed charges,,,1342.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2239.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1577.94,,,percent of total billed charges,,,,,,,,,,,,,,,2629.9,,,percent of total billed charges,,,2235.42,,,percent of total billed charges,,,,,,,,,,,,,,,2629.9,,,percent of total billed charges,,,1396.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1051.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2629.9,,,percent of total billed charges,,,,,,,,,,,,,,,210.39,,,percent of total billed charges,,,2629.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2629.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1549.54,,,percent of total billed charges,,
BEVACIZUMAB 100 MG/4 ML INJ,2500019341,CDM,636,RC,J9035,HCPCS,5024206001,NDC,,,,outpatient,facility,4,GR,2629.9,2629.9,47.59,2629.9,,74.16,,,fee schedule,,,,,,,,,2629.9,,,percent of total billed charges,,,94.05,,,fee schedule,,,88.98,,,fee schedule,,,,,,,,,88.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2629.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,69.77,,,fee schedule,,,2629.9,,,fee schedule,,,2629.9,,,percent of total billed charges,,,,,,,,,2629.9,,,percent of total billed charges,,,1611.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1873.8,,,percent of total billed charges,,,,,,,,,,,,,,,74.07,,,fee schedule,,,74.07,,,fee schedule,,,74.07,,,fee schedule,,,,,,,,,1551.64,,,percent of total billed charges,,,548.68,,,per diem,,,2629.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2629.9,,,percent of total billed charges,,,2235.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1396.74,,,percent of total billed charges,,,2629.9,,,percent of total billed charges,,,2629.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1774.13,,,percent of total billed charges,,,2128.12,,,percent of total billed charges,,,,,,,,,,,,,,,1051.96,,,percent of total billed charges,,,,,,,,,171.3,,,fee schedule,,,123.26,,,fee schedule,,,,,,,,,2629.9,,,percent of total billed charges,,,,,,,,,,,,,,,210.39,,,percent of total billed charges,,,2629.9,,,percent of total billed charges,,,,,,,,,,,,,,,2629.9,,,percent of total billed charges,,,2629.9,,,percent of total billed charges,,,,,,,,,73.21,,,fee schedule,,,,,,,,,,,,,,,63.45,,,fee schedule,,,84.6,,,fee schedule,,,47.59,,,fee schedule,,,75.2,,,fee schedule,,,2629.9,,,percent of total billed charges,,,2629.9,,,percent of total billed charges,,,2629.9,,,percent of total billed charges,,,,,,,,,1843.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1314.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1549.54,,,percent of total billed charges,,
BEVACIZUMAB 100 MG/4 ML INJ,2500019341,CDM,636,RC,J9035,HCPCS,5024206001,NDC,9214,APC,,outpatient,facility,4,GR,2629.9,2629.9,70.26,962.54,,,,,,,,75.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,73.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.92,,,fee schedule,,,,,,,,,962.54,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,73.19,,,fee schedule,,,,,,,,,,,,,,,76.85,,,fee schedule,,,76.85,,,fee schedule,,,,,,,,,73.19,,,fee schedule,,,73.19,,,fee schedule,,,76.85,,,fee schedule,,,,,,,,,,,,,,,109.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,73.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.26,,,fee schedule,,,78.31,,,fee schedule,,,76.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.19,,,fee schedule,,,73.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,76.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,73.19,,,fee schedule,,,,,,,,,91.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,91.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,73.19,,,fee schedule,,,73.19,,,fee schedule,,,,,,,,,,,,,,,73.19,,,fee schedule,,,,,,,,,73.19,,,fee schedule,,,75.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.19,,,fee schedule,,,,,,,,,,,,,,,76.12,,,fee schedule,,,73.19,,,fee schedule,,,,,,,,,73.19,,,fee schedule,,,,,,,,,73.19,,,fee schedule,,,76.85,,,fee schedule,,,,,,,,
BEVACIZUMAB 100 MG/4 ML INJ,2500019341,CDM,636,RC,J9035,HCPCS,5024206001,NDC,461,EAPG,,outpatient,facility,4,GR,2629.9,2629.9,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CETUXIMAB INJ 100MG,2500019350,CDM,636,RC,J9055,HCPCS,6673394823,NDC,,,,inpatient,facility,50,GR,2601.45,2601.45,208.12,2601.45,,,,,,,,,,,,,,2601.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.45,,,percent of total billed charges,,,,,,,,,2601.45,,,percent of total billed charges,,,1328.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2215.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1560.87,,,percent of total billed charges,,,,,,,,,,,,,,,2601.45,,,percent of total billed charges,,,2211.23,,,percent of total billed charges,,,,,,,,,,,,,,,2601.45,,,percent of total billed charges,,,1381.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1040.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.45,,,percent of total billed charges,,,,,,,,,,,,,,,208.12,,,percent of total billed charges,,,2601.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2601.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.77,,,percent of total billed charges,,
CETUXIMAB INJ 100MG,2500019350,CDM,636,RC,J9055,HCPCS,6673394823,NDC,,,,outpatient,facility,50,GR,2601.45,2601.45,47.15,2601.45,,73.49,,,fee schedule,,,,,,,,,2601.45,,,percent of total billed charges,,,98.17,,,fee schedule,,,92.87,,,fee schedule,,,,,,,,,92.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2601.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,57.56,,,fee schedule,,,2601.45,,,fee schedule,,,2601.45,,,percent of total billed charges,,,,,,,,,2601.45,,,percent of total billed charges,,,1594.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1853.53,,,percent of total billed charges,,,,,,,,,,,,,,,73.72,,,fee schedule,,,73.72,,,fee schedule,,,73.72,,,fee schedule,,,,,,,,,1534.86,,,percent of total billed charges,,,548.68,,,per diem,,,2601.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2601.45,,,percent of total billed charges,,,2211.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1381.63,,,percent of total billed charges,,,2601.45,,,percent of total billed charges,,,2601.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1754.94,,,percent of total billed charges,,,2105.09,,,percent of total billed charges,,,,,,,,,,,,,,,1040.58,,,percent of total billed charges,,,,,,,,,169.75,,,fee schedule,,,122.15,,,fee schedule,,,,,,,,,2601.45,,,percent of total billed charges,,,,,,,,,,,,,,,208.12,,,percent of total billed charges,,,2601.45,,,percent of total billed charges,,,,,,,,,,,,,,,2601.45,,,percent of total billed charges,,,2601.45,,,percent of total billed charges,,,,,,,,,72.54,,,fee schedule,,,,,,,,,,,,,,,62.87,,,fee schedule,,,83.83,,,fee schedule,,,47.15,,,fee schedule,,,78.49,,,fee schedule,,,2601.45,,,percent of total billed charges,,,2601.45,,,percent of total billed charges,,,2601.45,,,percent of total billed charges,,,,,,,,,1823.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1300.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1532.77,,,percent of total billed charges,,
CETUXIMAB INJ 100MG,2500019350,CDM,636,RC,J9055,HCPCS,6673394823,NDC,9215,APC,,outpatient,facility,50,GR,2601.45,2601.45,74.02,952.13,,,,,,,,79.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,77.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.87,,,fee schedule,,,,,,,,,952.13,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,77.1,,,fee schedule,,,,,,,,,,,,,,,80.96,,,fee schedule,,,80.96,,,fee schedule,,,,,,,,,77.1,,,fee schedule,,,77.1,,,fee schedule,,,80.96,,,fee schedule,,,,,,,,,,,,,,,115.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,77.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.02,,,fee schedule,,,82.5,,,fee schedule,,,80.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.1,,,fee schedule,,,77.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,80.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,77.1,,,fee schedule,,,,,,,,,96.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,96.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,77.1,,,fee schedule,,,77.1,,,fee schedule,,,,,,,,,,,,,,,77.1,,,fee schedule,,,,,,,,,77.1,,,fee schedule,,,79.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.1,,,fee schedule,,,,,,,,,,,,,,,80.18,,,fee schedule,,,77.1,,,fee schedule,,,,,,,,,77.1,,,fee schedule,,,,,,,,,77.1,,,fee schedule,,,80.96,,,fee schedule,,,,,,,,
CETUXIMAB INJ 100MG,2500019350,CDM,636,RC,J9055,HCPCS,6673394823,NDC,461,EAPG,,outpatient,facility,50,GR,2601.45,2601.45,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CETUXIMAB INJ 200 MG,2500019355,CDM,636,RC,J9055,HCPCS,6673395823,NDC,,,,inpatient,facility,100,ML,5306.96,5306.96,424.56,5306.96,,,,,,,,,,,,,,5306.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5306.96,,,percent of total billed charges,,,,,,,,,5306.96,,,percent of total billed charges,,,2709.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4519.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3184.18,,,percent of total billed charges,,,,,,,,,,,,,,,5306.96,,,percent of total billed charges,,,4510.92,,,percent of total billed charges,,,,,,,,,,,,,,,5306.96,,,percent of total billed charges,,,2818.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2122.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5306.96,,,percent of total billed charges,,,,,,,,,,,,,,,424.56,,,percent of total billed charges,,,5306.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5306.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3126.86,,,percent of total billed charges,,
CETUXIMAB INJ 200 MG,2500019355,CDM,636,RC,J9055,HCPCS,6673395823,NDC,,,,outpatient,facility,100,ML,5306.96,5306.96,47.15,5306.96,,73.49,,,fee schedule,,,,,,,,,5306.96,,,percent of total billed charges,,,98.17,,,fee schedule,,,92.87,,,fee schedule,,,,,,,,,92.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,5306.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,57.56,,,fee schedule,,,5306.96,,,fee schedule,,,5306.96,,,percent of total billed charges,,,,,,,,,5306.96,,,percent of total billed charges,,,3252.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3781.21,,,percent of total billed charges,,,,,,,,,,,,,,,73.72,,,fee schedule,,,73.72,,,fee schedule,,,73.72,,,fee schedule,,,,,,,,,3131.11,,,percent of total billed charges,,,548.68,,,per diem,,,5306.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5306.96,,,percent of total billed charges,,,4510.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2818.53,,,percent of total billed charges,,,5306.96,,,percent of total billed charges,,,5306.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3580.08,,,percent of total billed charges,,,4294.39,,,percent of total billed charges,,,,,,,,,,,,,,,2122.78,,,percent of total billed charges,,,,,,,,,169.75,,,fee schedule,,,122.15,,,fee schedule,,,,,,,,,5306.96,,,percent of total billed charges,,,,,,,,,,,,,,,424.56,,,percent of total billed charges,,,5306.96,,,percent of total billed charges,,,,,,,,,,,,,,,5306.96,,,percent of total billed charges,,,5306.96,,,percent of total billed charges,,,,,,,,,72.54,,,fee schedule,,,,,,,,,,,,,,,62.87,,,fee schedule,,,83.83,,,fee schedule,,,47.15,,,fee schedule,,,78.49,,,fee schedule,,,5306.96,,,percent of total billed charges,,,5306.96,,,percent of total billed charges,,,5306.96,,,percent of total billed charges,,,,,,,,,3720.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2653.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3126.86,,,percent of total billed charges,,
CETUXIMAB INJ 200 MG,2500019355,CDM,636,RC,J9055,HCPCS,6673395823,NDC,9215,APC,,outpatient,facility,100,ML,5306.96,5306.96,74.02,1942.35,,,,,,,,79.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,77.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.87,,,fee schedule,,,,,,,,,1942.35,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,77.1,,,fee schedule,,,,,,,,,,,,,,,80.96,,,fee schedule,,,80.96,,,fee schedule,,,,,,,,,77.1,,,fee schedule,,,77.1,,,fee schedule,,,80.96,,,fee schedule,,,,,,,,,,,,,,,115.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,77.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.02,,,fee schedule,,,82.5,,,fee schedule,,,80.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.1,,,fee schedule,,,77.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,80.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,77.1,,,fee schedule,,,,,,,,,96.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,96.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,77.1,,,fee schedule,,,77.1,,,fee schedule,,,,,,,,,,,,,,,77.1,,,fee schedule,,,,,,,,,77.1,,,fee schedule,,,79.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.1,,,fee schedule,,,,,,,,,,,,,,,80.18,,,fee schedule,,,77.1,,,fee schedule,,,,,,,,,77.1,,,fee schedule,,,,,,,,,77.1,,,fee schedule,,,80.96,,,fee schedule,,,,,,,,
CETUXIMAB INJ 200 MG,2500019355,CDM,636,RC,J9055,HCPCS,6673395823,NDC,461,EAPG,,outpatient,facility,100,ML,5306.96,5306.96,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEMETREXED 500MG INJ,2500019371,CDM,636,RC,J9305,HCPCS,2762301,NDC,,,,inpatient,facility,500,GR,13341.9,13341.9,1067.35,13341.9,,,,,,,,,,,,,,13341.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13341.9,,,percent of total billed charges,,,,,,,,,13341.9,,,percent of total billed charges,,,6812.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11363.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8005.14,,,percent of total billed charges,,,,,,,,,,,,,,,13341.9,,,percent of total billed charges,,,11340.62,,,percent of total billed charges,,,,,,,,,,,,,,,13341.9,,,percent of total billed charges,,,7085.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5336.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1067.35,,,percent of total billed charges,,,13341.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13341.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7861.05,,,percent of total billed charges,,
PEMETREXED 500MG INJ,2500019371,CDM,636,RC,J9305,HCPCS,2762301,NDC,,,,outpatient,facility,500,GR,13341.9,13341.9,3.97,13341.9,,3.97,,,fee schedule,,,,,,,,,13341.9,,,percent of total billed charges,,,7.29,,,fee schedule,,,6.9,,,fee schedule,,,,,,,,,6.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,13341.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,60.91,,,fee schedule,,,13341.9,,,fee schedule,,,13341.9,,,percent of total billed charges,,,,,,,,,13341.9,,,percent of total billed charges,,,8177.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9506.1,,,percent of total billed charges,,,,,,,,,,,,,,,4.37,,,fee schedule,,,4.37,,,fee schedule,,,4.37,,,fee schedule,,,,,,,,,7871.72,,,percent of total billed charges,,,548.68,,,per diem,,,13341.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13341.9,,,percent of total billed charges,,,11340.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7085.88,,,percent of total billed charges,,,13341.9,,,percent of total billed charges,,,13341.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9000.45,,,percent of total billed charges,,,10796.27,,,percent of total billed charges,,,,,,,,,,,,,,,5336.76,,,percent of total billed charges,,,,,,,,,117.32,,,fee schedule,,,84.42,,,fee schedule,,,,,,,,,13341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1067.35,,,percent of total billed charges,,,13341.9,,,percent of total billed charges,,,,,,,,,,,,,,,13341.9,,,percent of total billed charges,,,13341.9,,,percent of total billed charges,,,,,,,,,50.14,,,fee schedule,,,,,,,,,,,,,,,43.46,,,fee schedule,,,57.94,,,fee schedule,,,32.59,,,fee schedule,,,5.83,,,fee schedule,,,13341.9,,,percent of total billed charges,,,13341.9,,,percent of total billed charges,,,13341.9,,,percent of total billed charges,,,,,,,,,9354.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6670.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7861.05,,,percent of total billed charges,,
PEMETREXED 500MG INJ,2500019371,CDM,636,RC,J9305,HCPCS,2762301,NDC,9213,APC,,outpatient,facility,500,GR,13341.9,13341.9,5.06,4883.14,,,,,,,,5.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,5.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.32,,,fee schedule,,,,,,,,,4883.14,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,fee schedule,,,,,,,,,,,,,,,5.53,,,fee schedule,,,5.53,,,fee schedule,,,,,,,,,5.27,,,fee schedule,,,5.27,,,fee schedule,,,5.53,,,fee schedule,,,,,,,,,,,,,,,7.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.06,,,fee schedule,,,5.64,,,fee schedule,,,5.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,fee schedule,,,5.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,fee schedule,,,,,,,,,6.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,5.27,,,fee schedule,,,5.27,,,fee schedule,,,,,,,,,,,,,,,5.27,,,fee schedule,,,,,,,,,5.27,,,fee schedule,,,5.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,fee schedule,,,,,,,,,,,,,,,5.48,,,fee schedule,,,5.27,,,fee schedule,,,,,,,,,5.27,,,fee schedule,,,,,,,,,5.27,,,fee schedule,,,5.53,,,fee schedule,,,,,,,,
PEMETREXED 500MG INJ,2500019371,CDM,636,RC,J9305,HCPCS,2762301,NDC,460,EAPG,,outpatient,facility,500,GR,13341.9,13341.9,1604.23,2422.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2422.39,,,fee schedule,,,1604.23,,,fee schedule,,,2153.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEMETREXED 100 MG INJ,2500019372,CDM,636,RC,J9305,HCPCS,2764001,NDC,,,,inpatient,facility,100,GR,2668.38,2668.38,213.47,2668.38,,,,,,,,,,,,,,2668.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2668.38,,,percent of total billed charges,,,,,,,,,2668.38,,,percent of total billed charges,,,1362.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2272.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1601.03,,,percent of total billed charges,,,,,,,,,,,,,,,2668.38,,,percent of total billed charges,,,2268.12,,,percent of total billed charges,,,,,,,,,,,,,,,2668.38,,,percent of total billed charges,,,1417.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1067.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2668.38,,,percent of total billed charges,,,,,,,,,,,,,,,213.47,,,percent of total billed charges,,,2668.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2668.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1572.21,,,percent of total billed charges,,
PEMETREXED 100 MG INJ,2500019372,CDM,636,RC,J9305,HCPCS,2764001,NDC,,,,outpatient,facility,100,GR,2668.38,2668.38,3.97,2668.38,,3.97,,,fee schedule,,,,,,,,,2668.38,,,percent of total billed charges,,,7.29,,,fee schedule,,,6.9,,,fee schedule,,,,,,,,,6.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2668.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,60.91,,,fee schedule,,,2668.38,,,fee schedule,,,2668.38,,,percent of total billed charges,,,,,,,,,2668.38,,,percent of total billed charges,,,1635.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1901.22,,,percent of total billed charges,,,,,,,,,,,,,,,4.37,,,fee schedule,,,4.37,,,fee schedule,,,4.37,,,fee schedule,,,,,,,,,1574.34,,,percent of total billed charges,,,548.68,,,per diem,,,2668.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2668.38,,,percent of total billed charges,,,2268.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1417.18,,,percent of total billed charges,,,2668.38,,,percent of total billed charges,,,2668.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1800.09,,,percent of total billed charges,,,2159.25,,,percent of total billed charges,,,,,,,,,,,,,,,1067.35,,,percent of total billed charges,,,,,,,,,117.32,,,fee schedule,,,84.42,,,fee schedule,,,,,,,,,2668.38,,,percent of total billed charges,,,,,,,,,,,,,,,213.47,,,percent of total billed charges,,,2668.38,,,percent of total billed charges,,,,,,,,,,,,,,,2668.38,,,percent of total billed charges,,,2668.38,,,percent of total billed charges,,,,,,,,,50.14,,,fee schedule,,,,,,,,,,,,,,,43.46,,,fee schedule,,,57.94,,,fee schedule,,,32.59,,,fee schedule,,,5.83,,,fee schedule,,,2668.38,,,percent of total billed charges,,,2668.38,,,percent of total billed charges,,,2668.38,,,percent of total billed charges,,,,,,,,,1870.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1334.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1572.21,,,percent of total billed charges,,
PEMETREXED 100 MG INJ,2500019372,CDM,636,RC,J9305,HCPCS,2764001,NDC,9213,APC,,outpatient,facility,100,GR,2668.38,2668.38,5.06,976.63,,,,,,,,5.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,5.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.32,,,fee schedule,,,,,,,,,976.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,fee schedule,,,,,,,,,,,,,,,5.53,,,fee schedule,,,5.53,,,fee schedule,,,,,,,,,5.27,,,fee schedule,,,5.27,,,fee schedule,,,5.53,,,fee schedule,,,,,,,,,,,,,,,7.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.06,,,fee schedule,,,5.64,,,fee schedule,,,5.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,fee schedule,,,5.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,fee schedule,,,,,,,,,6.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,5.27,,,fee schedule,,,5.27,,,fee schedule,,,,,,,,,,,,,,,5.27,,,fee schedule,,,,,,,,,5.27,,,fee schedule,,,5.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,fee schedule,,,,,,,,,,,,,,,5.48,,,fee schedule,,,5.27,,,fee schedule,,,,,,,,,5.27,,,fee schedule,,,,,,,,,5.27,,,fee schedule,,,5.53,,,fee schedule,,,,,,,,
PEMETREXED 100 MG INJ,2500019372,CDM,636,RC,J9305,HCPCS,2764001,NDC,460,EAPG,,outpatient,facility,100,GR,2668.38,2668.38,1604.23,2422.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2422.39,,,fee schedule,,,1604.23,,,fee schedule,,,2153.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MILRINONE/D5W 20MG/100ML INJ,2500019390,CDM,636,RC,J2260,HCPCS,409277623,NDC,,,,inpatient,facility,100,UN,52.9,52.9,4.23,52.9,,,,,,,,,,,,,,52.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.9,,,percent of total billed charges,,,,,,,,,52.9,,,percent of total billed charges,,,27.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.74,,,percent of total billed charges,,,,,,,,,,,,,,,52.9,,,percent of total billed charges,,,44.96,,,percent of total billed charges,,,,,,,,,,,,,,,52.9,,,percent of total billed charges,,,28.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,52.9,,,percent of total billed charges,,,,,,,,,,,,,,,4.23,,,percent of total billed charges,,,52.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.17,,,percent of total billed charges,,
MILRINONE/D5W 20MG/100ML INJ,2500019390,CDM,636,RC,J2260,HCPCS,409277623,NDC,,,,outpatient,facility,100,UN,52.9,52.9,1.44,548.68,,37.51,,,percent of total billed charges,,,12.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,52.9,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,52.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,19.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,52.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,52.9,,,fee schedule,,,52.9,,,percent of total billed charges,,,,,,,,,52.9,,,percent of total billed charges,,,32.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,31.21,,,percent of total billed charges,,,548.68,,,per diem,,,52.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,52.9,,,percent of total billed charges,,,44.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.1,,,percent of total billed charges,,,52.9,,,percent of total billed charges,,,52.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.69,,,percent of total billed charges,,,42.81,,,percent of total billed charges,,,,,,,,,,,,,,,21.16,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,52.9,,,percent of total billed charges,,,52.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,52.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.23,,,percent of total billed charges,,,52.9,,,percent of total billed charges,,,,,,,,,,,,,,,52.9,,,percent of total billed charges,,,52.9,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.44,,,fee schedule,,,52.9,,,percent of total billed charges,,,52.9,,,percent of total billed charges,,,52.9,,,percent of total billed charges,,,,,,,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,31.17,,,percent of total billed charges,,
MILRINONE/D5W 20MG/100ML INJ,2500019390,CDM,636,RC,J2260,HCPCS,409277623,NDC,999,EAPG,,outpatient,facility,100,UN,52.9,52.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
D5W-LR KCL 40 MEQ 1000 ML,2500019420,CDM,636,RC,J3480,HCPCS,409711309,NDC,,,,inpatient,facility,1000,UN,33,33,2.64,33,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,16.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,17.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.44,,,percent of total billed charges,,
D5W-LR KCL 40 MEQ 1000 ML,2500019420,CDM,636,RC,J3480,HCPCS,409711309,NDC,,,,outpatient,facility,1000,UN,33,33,0.11,548.68,,23.4,,,percent of total billed charges,,,8.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,33,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,33,,,fee schedule,,,33,,,percent of total billed charges,,,,,,,,,33,,,percent of total billed charges,,,20.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,19.47,,,percent of total billed charges,,,548.68,,,per diem,,,33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,33,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.53,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.26,,,percent of total billed charges,,,26.7,,,percent of total billed charges,,,,,,,,,,,,,,,13.2,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,33,,,percent of total billed charges,,,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.64,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.11,,,fee schedule,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,33,,,percent of total billed charges,,,,,,,,,23.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,19.44,,,percent of total billed charges,,
D5W-LR KCL 40 MEQ 1000 ML,2500019420,CDM,636,RC,J3480,HCPCS,409711309,NDC,999,EAPG,,outpatient,facility,1000,UN,33,33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AZACITIDINE INJ 100 MG,2500019490,CDM,636,RC,J9025,HCPCS,1672930610,NDC,,,,inpatient,facility,100,GR,2038.14,2038.14,163.05,2038.14,,,,,,,,,,,,,,2038.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2038.14,,,percent of total billed charges,,,,,,,,,2038.14,,,percent of total billed charges,,,1040.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1735.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1222.88,,,percent of total billed charges,,,,,,,,,,,,,,,2038.14,,,percent of total billed charges,,,1732.42,,,percent of total billed charges,,,,,,,,,,,,,,,2038.14,,,percent of total billed charges,,,1082.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,815.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2038.14,,,percent of total billed charges,,,,,,,,,,,,,,,163.05,,,percent of total billed charges,,,2038.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2038.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1200.87,,,percent of total billed charges,,
AZACITIDINE INJ 100 MG,2500019490,CDM,636,RC,J9025,HCPCS,1672930610,NDC,,,,outpatient,facility,100,GR,2038.14,2038.14,0.35,2038.14,,0.41,,,fee schedule,,,497.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2038.14,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,2038.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,745.96,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.97,,,fee schedule,,,2038.14,,,fee schedule,,,2038.14,,,percent of total billed charges,,,,,,,,,2038.14,,,percent of total billed charges,,,1249.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1452.17,,,percent of total billed charges,,,,,,,,,,,,,,,0.35,,,fee schedule,,,0.35,,,fee schedule,,,0.35,,,fee schedule,,,,,,,,,1202.5,,,percent of total billed charges,,,548.68,,,per diem,,,2038.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2038.14,,,percent of total billed charges,,,1732.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1082.46,,,percent of total billed charges,,,2038.14,,,percent of total billed charges,,,2038.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1374.93,,,percent of total billed charges,,,1649.26,,,percent of total billed charges,,,,,,,,,,,,,,,815.26,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,2038.14,,,percent of total billed charges,,,2038.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2038.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,163.05,,,percent of total billed charges,,,2038.14,,,percent of total billed charges,,,,,,,,,,,,,,,2038.14,,,percent of total billed charges,,,2038.14,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.45,,,fee schedule,,,2038.14,,,percent of total billed charges,,,2038.14,,,percent of total billed charges,,,2038.14,,,percent of total billed charges,,,,,,,,,1428.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1019.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1200.87,,,percent of total billed charges,,
AZACITIDINE INJ 100 MG,2500019490,CDM,636,RC,J9025,HCPCS,1672930610,NDC,431,EAPG,,outpatient,facility,100,GR,2038.14,2038.14,42.81,64.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.64,,,fee schedule,,,42.81,,,fee schedule,,,57.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.81,,,fee schedule,,,42.81,,,fee schedule,,,42.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,42.81,,,fee schedule,,,,,,,,,,,,,,,42.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MEMANTINE HCL 10 MG TAB,2500019530,CDM,637,RC,591387544,NDC,,,,,,inpatient,facility,10,UN,20.13,20.13,1.61,20.13,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,,,,20.13,,,percent of total billed charges,,,10.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.08,,,percent of total billed charges,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,17.11,,,percent of total billed charges,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,10.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.61,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.86,,,percent of total billed charges,,
MEMANTINE HCL 10 MG TAB,2500019530,CDM,637,RC,591387544,NDC,,,,,,outpatient,facility,10,UN,20.13,20.13,1.61,548.68,,14.27,,,percent of total billed charges,,,4.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,20.13,,,percent of total billed charges,,,12.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,14.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,14.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.37,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,20.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,20.13,,,fee schedule,,,20.13,,,percent of total billed charges,,,,,,,,,20.13,,,percent of total billed charges,,,12.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.34,,,percent of total billed charges,,,,,,,,,,,,,,,10.87,,,percent of total billed charges,,,10.47,,,percent of total billed charges,,,11.07,,,percent of total billed charges,,,,,,,,,11.88,,,percent of total billed charges,,,548.68,,,per diem,,,20.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,20.13,,,percent of total billed charges,,,17.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.69,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.58,,,percent of total billed charges,,,16.29,,,percent of total billed charges,,,,,,,,,,,,,,,8.05,,,percent of total billed charges,,,,,,,,,7.45,,,percent of total billed charges,,,7.45,,,percent of total billed charges,,,,,,,,,20.13,,,percent of total billed charges,,,20.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.61,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,,,,,,,18.72,,,percent of total billed charges,,,,,,,,,,,,,,,18.72,,,percent of total billed charges,,,18.72,,,percent of total billed charges,,,18.72,,,percent of total billed charges,,,15.1,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,20.13,,,percent of total billed charges,,,,,,,,,14.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.86,,,percent of total billed charges,,
MEMANTINE HCL 10 MG TAB,2500019530,CDM,637,RC,591387544,NDC,999,EAPG,,,,outpatient,facility,10,UN,20.13,20.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MITOMYCIN 20MG VIAL,2500019531,CDM,636,RC,J9280,HCPCS,1672910811,NDC,,,,inpatient,facility,20,GR,2335.81,2335.81,186.86,2335.81,,,,,,,,,,,,,,2335.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2335.81,,,percent of total billed charges,,,,,,,,,2335.81,,,percent of total billed charges,,,1192.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1989.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1401.49,,,percent of total billed charges,,,,,,,,,,,,,,,2335.81,,,percent of total billed charges,,,1985.44,,,percent of total billed charges,,,,,,,,,,,,,,,2335.81,,,percent of total billed charges,,,1240.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,934.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2335.81,,,percent of total billed charges,,,,,,,,,,,,,,,186.86,,,percent of total billed charges,,,2335.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2335.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1376.26,,,percent of total billed charges,,
MITOMYCIN 20MG VIAL,2500019531,CDM,636,RC,J9280,HCPCS,1672910811,NDC,,,,outpatient,facility,20,GR,2335.81,2335.81,37.05,2335.81,,67.03,,,fee schedule,,,,,,,,,2335.81,,,percent of total billed charges,,,70.3,,,fee schedule,,,66.51,,,fee schedule,,,,,,,,,66.51,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2335.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2335.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2335.81,,,fee schedule,,,2335.81,,,percent of total billed charges,,,,,,,,,2335.81,,,percent of total billed charges,,,1431.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1664.26,,,percent of total billed charges,,,,,,,,,,,,,,,63.35,,,fee schedule,,,63.35,,,fee schedule,,,63.35,,,fee schedule,,,,,,,,,1378.13,,,percent of total billed charges,,,548.68,,,per diem,,,2335.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2335.81,,,percent of total billed charges,,,1985.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1240.55,,,percent of total billed charges,,,2335.81,,,percent of total billed charges,,,2335.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1575.74,,,percent of total billed charges,,,1890.14,,,percent of total billed charges,,,,,,,,,,,,,,,934.32,,,percent of total billed charges,,,,,,,,,133.39,,,fee schedule,,,95.98,,,fee schedule,,,,,,,,,2335.81,,,percent of total billed charges,,,,,,,,,,,,,,,186.86,,,percent of total billed charges,,,2335.81,,,percent of total billed charges,,,,,,,,,,,,,,,2335.81,,,percent of total billed charges,,,2335.81,,,percent of total billed charges,,,,,,,,,57,,,fee schedule,,,,,,,,,,,,,,,49.41,,,fee schedule,,,65.88,,,fee schedule,,,37.05,,,fee schedule,,,56.21,,,fee schedule,,,2335.81,,,percent of total billed charges,,,2335.81,,,percent of total billed charges,,,2335.81,,,percent of total billed charges,,,,,,,,,1637.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1167.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1376.26,,,percent of total billed charges,,
MITOMYCIN 20MG VIAL,2500019531,CDM,636,RC,J9280,HCPCS,1672910811,NDC,1232,APC,,outpatient,facility,20,GR,2335.81,2335.81,44.5,854.91,,,,,,,,47.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,46.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.81,,,fee schedule,,,,,,,,,854.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,46.35,,,fee schedule,,,,,,,,,,,,,,,48.67,,,fee schedule,,,48.67,,,fee schedule,,,,,,,,,46.35,,,fee schedule,,,46.35,,,fee schedule,,,48.67,,,fee schedule,,,,,,,,,,,,,,,69.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.5,,,fee schedule,,,49.59,,,fee schedule,,,48.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.35,,,fee schedule,,,46.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,48.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,46.35,,,fee schedule,,,,,,,,,57.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,57.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,46.35,,,fee schedule,,,46.35,,,fee schedule,,,,,,,,,,,,,,,46.35,,,fee schedule,,,,,,,,,46.35,,,fee schedule,,,47.74,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.35,,,fee schedule,,,,,,,,,,,,,,,48.2,,,fee schedule,,,46.35,,,fee schedule,,,,,,,,,46.35,,,fee schedule,,,,,,,,,46.35,,,fee schedule,,,48.67,,,fee schedule,,,,,,,,
MITOMYCIN 20MG VIAL,2500019531,CDM,636,RC,J9280,HCPCS,1672910811,NDC,433,EAPG,,outpatient,facility,20,GR,2335.81,2335.81,349.48,527.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,527.71,,,fee schedule,,,349.48,,,fee schedule,,,469.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.48,,,fee schedule,,,349.48,,,fee schedule,,,349.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,349.48,,,fee schedule,,,,,,,,,,,,,,,349.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPLERENONE 25MG TABLET,2500019540,CDM,637,RC,378103093,NDC,,,,,,inpatient,facility,25,UN,13.76,13.76,1.1,13.76,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,13.76,,,percent of total billed charges,,,7.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.26,,,percent of total billed charges,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,11.7,,,percent of total billed charges,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,7.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.11,,,percent of total billed charges,,
EPLERENONE 25MG TABLET,2500019540,CDM,637,RC,378103093,NDC,,,,,,outpatient,facility,25,UN,13.76,13.76,1.1,548.68,,9.76,,,percent of total billed charges,,,3.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.76,,,percent of total billed charges,,,8.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.04,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.76,,,fee schedule,,,13.76,,,percent of total billed charges,,,,,,,,,13.76,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.8,,,percent of total billed charges,,,,,,,,,,,,,,,7.43,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,7.57,,,percent of total billed charges,,,,,,,,,8.12,,,percent of total billed charges,,,548.68,,,per diem,,,13.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.76,,,percent of total billed charges,,,11.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.31,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.28,,,percent of total billed charges,,,11.13,,,percent of total billed charges,,,,,,,,,,,,,,,5.5,,,percent of total billed charges,,,,,,,,,5.09,,,percent of total billed charges,,,5.09,,,percent of total billed charges,,,,,,,,,13.76,,,percent of total billed charges,,,13.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.1,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,,,,,,,12.8,,,percent of total billed charges,,,,,,,,,,,,,,,12.8,,,percent of total billed charges,,,12.8,,,percent of total billed charges,,,12.8,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,,,,,,,9.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.11,,,percent of total billed charges,,
EPLERENONE 25MG TABLET,2500019540,CDM,637,RC,378103093,NDC,999,EAPG,,,,outpatient,facility,25,UN,13.76,13.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NATALIZUMAB 300 MG INJ,2500019560,CDM,636,RC,J2323,HCPCS,6440600801,NDC,,,,inpatient,facility,15,ML,25924.27,25924.27,2073.94,25924.27,,,,,,,,,,,,,,25924.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25924.27,,,percent of total billed charges,,,,,,,,,25924.27,,,percent of total billed charges,,,13236.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22079.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15554.56,,,percent of total billed charges,,,,,,,,,,,,,,,25924.27,,,percent of total billed charges,,,22035.63,,,percent of total billed charges,,,,,,,,,,,,,,,25924.27,,,percent of total billed charges,,,13768.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10369.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,25924.27,,,percent of total billed charges,,,,,,,,,,,,,,,2073.94,,,percent of total billed charges,,,25924.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25924.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15274.58,,,percent of total billed charges,,
NATALIZUMAB 300 MG INJ,2500019560,CDM,636,RC,J2323,HCPCS,6440600801,NDC,,,,outpatient,facility,15,ML,25924.27,25924.27,12.1,25924.27,,18382.9,,,percent of total billed charges,,,,,,,,,25924.27,,,percent of total billed charges,,,31.24,,,fee schedule,,,29.56,,,fee schedule,,,,,,,,,29.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,25924.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,12.1,,,fee schedule,,,25924.27,,,fee schedule,,,25924.27,,,percent of total billed charges,,,,,,,,,25924.27,,,percent of total billed charges,,,15888.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18471.04,,,percent of total billed charges,,,,,,,,,,,,,,,24.45,,,fee schedule,,,24.45,,,fee schedule,,,24.45,,,fee schedule,,,,,,,,,15295.32,,,percent of total billed charges,,,548.68,,,per diem,,,25924.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,25924.27,,,percent of total billed charges,,,22035.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13768.38,,,percent of total billed charges,,,25924.27,,,percent of total billed charges,,,25924.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17488.51,,,percent of total billed charges,,,20977.92,,,percent of total billed charges,,,,,,,,,,,,,,,10369.71,,,percent of total billed charges,,,,,,,,,59.04,,,fee schedule,,,42.49,,,fee schedule,,,,,,,,,25924.27,,,percent of total billed charges,,,,,,,,,,,,,,,2073.94,,,percent of total billed charges,,,25924.27,,,percent of total billed charges,,,,,,,,,,,,,,,25924.27,,,percent of total billed charges,,,25924.27,,,percent of total billed charges,,,,,,,,,25.23,,,fee schedule,,,,,,,,,,,,,,,21.87,,,fee schedule,,,29.16,,,fee schedule,,,16.4,,,fee schedule,,,24.98,,,fee schedule,,,25924.27,,,percent of total billed charges,,,25924.27,,,percent of total billed charges,,,25924.27,,,percent of total billed charges,,,,,,,,,18175.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12962.14,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15274.58,,,percent of total billed charges,,
NATALIZUMAB 300 MG INJ,2500019560,CDM,636,RC,J2323,HCPCS,6440600801,NDC,9126,APC,,outpatient,facility,15,ML,25924.27,25924.27,22.92,9488.28,,,,,,,,24.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,23.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.12,,,fee schedule,,,,,,,,,9488.28,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,23.88,,,fee schedule,,,,,,,,,,,,,,,25.07,,,fee schedule,,,25.07,,,fee schedule,,,,,,,,,23.88,,,fee schedule,,,23.88,,,fee schedule,,,25.07,,,fee schedule,,,,,,,,,,,,,,,35.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,23.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.92,,,fee schedule,,,25.55,,,fee schedule,,,25.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.88,,,fee schedule,,,23.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,24.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,23.88,,,fee schedule,,,,,,,,,29.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,23.88,,,fee schedule,,,23.88,,,fee schedule,,,,,,,,,,,,,,,23.88,,,fee schedule,,,,,,,,,23.88,,,fee schedule,,,24.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.88,,,fee schedule,,,,,,,,,,,,,,,24.84,,,fee schedule,,,23.88,,,fee schedule,,,,,,,,,23.88,,,fee schedule,,,,,,,,,23.88,,,fee schedule,,,25.07,,,fee schedule,,,,,,,,
NATALIZUMAB 300 MG INJ,2500019560,CDM,636,RC,J2323,HCPCS,6440600801,NDC,463,EAPG,,outpatient,facility,15,ML,25924.27,25924.27,7053.67,10651.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10651.04,,,fee schedule,,,7053.67,,,fee schedule,,,9468.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RALTEGRAVIR 400 MG TAB,2500019577,CDM,637,RC,6022761,NDC,,,,,,inpatient,facility,400,UN,109.82,109.82,8.79,109.82,,,,,,,,,,,,,,109.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.82,,,percent of total billed charges,,,,,,,,,109.82,,,percent of total billed charges,,,56.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.89,,,percent of total billed charges,,,,,,,,,,,,,,,109.82,,,percent of total billed charges,,,93.35,,,percent of total billed charges,,,,,,,,,,,,,,,109.82,,,percent of total billed charges,,,58.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,109.82,,,percent of total billed charges,,,,,,,,,,,,,,,8.79,,,percent of total billed charges,,,109.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.71,,,percent of total billed charges,,
RALTEGRAVIR 400 MG TAB,2500019577,CDM,637,RC,6022761,NDC,,,,,,outpatient,facility,400,UN,109.82,109.82,8.79,548.68,,77.87,,,percent of total billed charges,,,26.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,109.82,,,percent of total billed charges,,,68.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,77.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,77.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,109.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,40.19,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,109.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,109.82,,,fee schedule,,,109.82,,,percent of total billed charges,,,,,,,,,109.82,,,percent of total billed charges,,,67.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.25,,,percent of total billed charges,,,,,,,,,,,,,,,59.3,,,percent of total billed charges,,,57.11,,,percent of total billed charges,,,60.4,,,percent of total billed charges,,,,,,,,,64.79,,,percent of total billed charges,,,548.68,,,per diem,,,109.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,109.82,,,percent of total billed charges,,,93.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.33,,,percent of total billed charges,,,109.82,,,percent of total billed charges,,,109.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.08,,,percent of total billed charges,,,88.87,,,percent of total billed charges,,,,,,,,,,,,,,,43.93,,,percent of total billed charges,,,,,,,,,40.63,,,percent of total billed charges,,,40.63,,,percent of total billed charges,,,,,,,,,109.82,,,percent of total billed charges,,,109.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,109.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.79,,,percent of total billed charges,,,109.82,,,percent of total billed charges,,,,,,,,,,,,,,,109.82,,,percent of total billed charges,,,109.82,,,percent of total billed charges,,,,,,,,,102.15,,,percent of total billed charges,,,,,,,,,,,,,,,102.15,,,percent of total billed charges,,,102.15,,,percent of total billed charges,,,102.15,,,percent of total billed charges,,,82.36,,,percent of total billed charges,,,109.82,,,percent of total billed charges,,,109.82,,,percent of total billed charges,,,109.82,,,percent of total billed charges,,,,,,,,,76.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,64.71,,,percent of total billed charges,,
RALTEGRAVIR 400 MG TAB,2500019577,CDM,637,RC,6022761,NDC,999,EAPG,,,,outpatient,facility,400,UN,109.82,109.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENDAMUSTINE 25 MG INJ TREANDA,2500019579,CDM,636,RC,J9033,HCPCS,6345939008,NDC,,,,inpatient,facility,25,GR,2942.08,2942.08,235.37,2942.08,,,,,,,,,,,,,,2942.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2942.08,,,percent of total billed charges,,,,,,,,,2942.08,,,percent of total billed charges,,,1502.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2505.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1765.25,,,percent of total billed charges,,,,,,,,,,,,,,,2942.08,,,percent of total billed charges,,,2500.77,,,percent of total billed charges,,,,,,,,,,,,,,,2942.08,,,percent of total billed charges,,,1562.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1176.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2942.08,,,percent of total billed charges,,,,,,,,,,,,,,,235.37,,,percent of total billed charges,,,2942.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2942.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1733.47,,,percent of total billed charges,,
BENDAMUSTINE 25 MG INJ TREANDA,2500019579,CDM,636,RC,J9033,HCPCS,6345939008,NDC,,,,outpatient,facility,25,GR,2942.08,2942.08,5.57,2942.08,,2086.23,,,percent of total billed charges,,,,,,,,,2942.08,,,percent of total billed charges,,,6.96,,,fee schedule,,,6.58,,,fee schedule,,,,,,,,,6.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2942.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2942.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2942.08,,,fee schedule,,,2942.08,,,percent of total billed charges,,,,,,,,,2942.08,,,percent of total billed charges,,,1803.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2096.23,,,percent of total billed charges,,,,,,,,,,,,,,,9.19,,,fee schedule,,,9.19,,,fee schedule,,,9.19,,,fee schedule,,,,,,,,,1735.83,,,percent of total billed charges,,,548.68,,,per diem,,,2942.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2942.08,,,percent of total billed charges,,,2500.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1562.54,,,percent of total billed charges,,,2942.08,,,percent of total billed charges,,,2942.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1984.73,,,percent of total billed charges,,,2380.73,,,percent of total billed charges,,,,,,,,,,,,,,,1176.83,,,percent of total billed charges,,,,,,,,,40.61,,,fee schedule,,,29.23,,,fee schedule,,,,,,,,,2942.08,,,percent of total billed charges,,,,,,,,,,,,,,,235.37,,,percent of total billed charges,,,2942.08,,,percent of total billed charges,,,,,,,,,,,,,,,2942.08,,,percent of total billed charges,,,2942.08,,,percent of total billed charges,,,,,,,,,17.36,,,fee schedule,,,,,,,,,,,,,,,15.05,,,fee schedule,,,20.06,,,fee schedule,,,11.28,,,fee schedule,,,5.57,,,fee schedule,,,2942.08,,,percent of total billed charges,,,2942.08,,,percent of total billed charges,,,2942.08,,,percent of total billed charges,,,,,,,,,2062.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1471.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1733.47,,,percent of total billed charges,,
BENDAMUSTINE 25 MG INJ TREANDA,2500019579,CDM,636,RC,J9033,HCPCS,6345939008,NDC,9243,APC,,outpatient,facility,25,GR,2942.08,2942.08,1.73,1076.8,,,,,,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.82,,,fee schedule,,,,,,,,,1076.8,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,1.89,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,1.8,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,,,,,,,,2.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.73,,,fee schedule,,,1.93,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,1.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,2.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,1.8,,,fee schedule,,,1.8,,,fee schedule,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,1.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.8,,,fee schedule,,,,,,,,,,,,,,,1.87,,,fee schedule,,,1.8,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,,,,,,,1.8,,,fee schedule,,,1.89,,,fee schedule,,,,,,,,
BENDAMUSTINE 25 MG INJ TREANDA,2500019579,CDM,636,RC,J9033,HCPCS,6345939008,NDC,461,EAPG,,outpatient,facility,25,GR,2942.08,2942.08,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIOTROPIUM BR INHLA DEVICE,2500019601,CDM,637,RC,597007575,NDC,,,,,,inpatient,facility,90,UN,66.92,66.92,5.35,66.92,,,,,,,,,,,,,,66.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.92,,,percent of total billed charges,,,,,,,,,66.92,,,percent of total billed charges,,,34.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.15,,,percent of total billed charges,,,,,,,,,,,,,,,66.92,,,percent of total billed charges,,,56.88,,,percent of total billed charges,,,,,,,,,,,,,,,66.92,,,percent of total billed charges,,,35.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,66.92,,,percent of total billed charges,,,,,,,,,,,,,,,5.35,,,percent of total billed charges,,,66.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.43,,,percent of total billed charges,,
TIOTROPIUM BR INHLA DEVICE,2500019601,CDM,637,RC,597007575,NDC,,,,,,outpatient,facility,90,UN,66.92,66.92,5.35,548.68,,47.45,,,percent of total billed charges,,,16.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,66.92,,,percent of total billed charges,,,41.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,47.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,47.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,66.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,24.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,66.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,66.92,,,fee schedule,,,66.92,,,percent of total billed charges,,,,,,,,,66.92,,,percent of total billed charges,,,41.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.68,,,percent of total billed charges,,,,,,,,,,,,,,,36.14,,,percent of total billed charges,,,34.8,,,percent of total billed charges,,,36.81,,,percent of total billed charges,,,,,,,,,39.48,,,percent of total billed charges,,,548.68,,,per diem,,,66.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,66.92,,,percent of total billed charges,,,56.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.54,,,percent of total billed charges,,,66.92,,,percent of total billed charges,,,66.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.14,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,26.77,,,percent of total billed charges,,,,,,,,,24.76,,,percent of total billed charges,,,24.76,,,percent of total billed charges,,,,,,,,,66.92,,,percent of total billed charges,,,66.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,66.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.35,,,percent of total billed charges,,,66.92,,,percent of total billed charges,,,,,,,,,,,,,,,66.92,,,percent of total billed charges,,,66.92,,,percent of total billed charges,,,,,,,,,62.25,,,percent of total billed charges,,,,,,,,,,,,,,,62.25,,,percent of total billed charges,,,62.25,,,percent of total billed charges,,,62.25,,,percent of total billed charges,,,50.19,,,percent of total billed charges,,,66.92,,,percent of total billed charges,,,66.92,,,percent of total billed charges,,,66.92,,,percent of total billed charges,,,,,,,,,46.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,39.43,,,percent of total billed charges,,
TIOTROPIUM BR INHLA DEVICE,2500019601,CDM,637,RC,597007575,NDC,999,EAPG,,,,outpatient,facility,90,UN,66.92,66.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METOPROLOL SUCC 25 MG TABCR,2500019604,CDM,637,RC,904632261,NDC,,,,,,inpatient,facility,25,UN,2.9,2.9,0.23,2.9,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,2.9,,,percent of total billed charges,,,1.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,
METOPROLOL SUCC 25 MG TABCR,2500019604,CDM,637,RC,904632261,NDC,,,,,,outpatient,facility,25,UN,2.9,2.9,0.23,548.68,,2.06,,,percent of total billed charges,,,0.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.9,,,percent of total billed charges,,,1.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.04,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.06,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.9,,,fee schedule,,,2.9,,,percent of total billed charges,,,,,,,,,2.9,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,1.59,,,percent of total billed charges,,,,,,,,,1.71,,,percent of total billed charges,,,548.68,,,per diem,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.9,,,percent of total billed charges,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.54,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,1.07,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,2.9,,,percent of total billed charges,,,2.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,2.7,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,2.17,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,2.9,,,percent of total billed charges,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.71,,,percent of total billed charges,,
METOPROLOL SUCC 25 MG TABCR,2500019604,CDM,637,RC,904632261,NDC,999,EAPG,,,,outpatient,facility,25,UN,2.9,2.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DULOXETINE HCL 60 MG ORAL,2500019607,CDM,637,RC,5723701999,NDC,,,,,,inpatient,facility,60,UN,25.91,25.91,2.07,25.91,,,,,,,,,,,,,,25.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.91,,,percent of total billed charges,,,,,,,,,25.91,,,percent of total billed charges,,,13.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.55,,,percent of total billed charges,,,,,,,,,,,,,,,25.91,,,percent of total billed charges,,,22.02,,,percent of total billed charges,,,,,,,,,,,,,,,25.91,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,25.91,,,percent of total billed charges,,,,,,,,,,,,,,,2.07,,,percent of total billed charges,,,25.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.27,,,percent of total billed charges,,
DULOXETINE HCL 60 MG ORAL,2500019607,CDM,637,RC,5723701999,NDC,,,,,,outpatient,facility,60,UN,25.91,25.91,2.07,548.68,,18.37,,,percent of total billed charges,,,6.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,25.91,,,percent of total billed charges,,,16.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,18.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,18.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,25.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.48,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,25.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,25.91,,,fee schedule,,,25.91,,,percent of total billed charges,,,,,,,,,25.91,,,percent of total billed charges,,,15.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.46,,,percent of total billed charges,,,,,,,,,,,,,,,13.99,,,percent of total billed charges,,,13.47,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,15.29,,,percent of total billed charges,,,548.68,,,per diem,,,25.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,25.91,,,percent of total billed charges,,,22.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.76,,,percent of total billed charges,,,25.91,,,percent of total billed charges,,,25.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.48,,,percent of total billed charges,,,20.97,,,percent of total billed charges,,,,,,,,,,,,,,,10.36,,,percent of total billed charges,,,,,,,,,9.59,,,percent of total billed charges,,,9.59,,,percent of total billed charges,,,,,,,,,25.91,,,percent of total billed charges,,,25.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.07,,,percent of total billed charges,,,25.91,,,percent of total billed charges,,,,,,,,,,,,,,,25.91,,,percent of total billed charges,,,25.91,,,percent of total billed charges,,,,,,,,,24.1,,,percent of total billed charges,,,,,,,,,,,,,,,24.1,,,percent of total billed charges,,,24.1,,,percent of total billed charges,,,24.1,,,percent of total billed charges,,,19.43,,,percent of total billed charges,,,25.91,,,percent of total billed charges,,,25.91,,,percent of total billed charges,,,25.91,,,percent of total billed charges,,,,,,,,,18.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15.27,,,percent of total billed charges,,
DULOXETINE HCL 60 MG ORAL,2500019607,CDM,637,RC,5723701999,NDC,999,EAPG,,,,outpatient,facility,60,UN,25.91,25.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACLITAXEL PROTEIN BND 100MG,2500019608,CDM,636,RC,J9264,HCPCS,6881713450,NDC,,,,inpatient,facility,100,GR,5214.19,5214.19,417.14,5214.19,,,,,,,,,,,,,,5214.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5214.19,,,percent of total billed charges,,,,,,,,,5214.19,,,percent of total billed charges,,,2662.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4440.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3128.51,,,percent of total billed charges,,,,,,,,,,,,,,,5214.19,,,percent of total billed charges,,,4432.06,,,percent of total billed charges,,,,,,,,,,,,,,,5214.19,,,percent of total billed charges,,,2769.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2085.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5214.19,,,percent of total billed charges,,,,,,,,,,,,,,,417.14,,,percent of total billed charges,,,5214.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5214.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3072.2,,,percent of total billed charges,,
PACLITAXEL PROTEIN BND 100MG,2500019608,CDM,636,RC,J9264,HCPCS,6881713450,NDC,,,,outpatient,facility,100,GR,5214.19,5214.19,8.32,5214.19,,13.71,,,fee schedule,,,,,,,,,5214.19,,,percent of total billed charges,,,17.19,,,fee schedule,,,16.26,,,fee schedule,,,,,,,,,16.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,5214.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.8,,,fee schedule,,,5214.19,,,fee schedule,,,5214.19,,,percent of total billed charges,,,,,,,,,5214.19,,,percent of total billed charges,,,3195.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3715.11,,,percent of total billed charges,,,,,,,,,,,,,,,14.29,,,fee schedule,,,14.29,,,fee schedule,,,14.29,,,fee schedule,,,,,,,,,3076.37,,,percent of total billed charges,,,548.68,,,per diem,,,5214.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5214.19,,,percent of total billed charges,,,4432.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2769.26,,,percent of total billed charges,,,5214.19,,,percent of total billed charges,,,5214.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3517.49,,,percent of total billed charges,,,4219.32,,,percent of total billed charges,,,,,,,,,,,,,,,2085.68,,,percent of total billed charges,,,,,,,,,29.95,,,fee schedule,,,21.55,,,fee schedule,,,,,,,,,5214.19,,,percent of total billed charges,,,,,,,,,,,,,,,417.14,,,percent of total billed charges,,,5214.19,,,percent of total billed charges,,,,,,,,,,,,,,,5214.19,,,percent of total billed charges,,,5214.19,,,percent of total billed charges,,,,,,,,,12.8,,,fee schedule,,,,,,,,,,,,,,,11.09,,,fee schedule,,,14.79,,,fee schedule,,,8.32,,,fee schedule,,,13.74,,,fee schedule,,,5214.19,,,percent of total billed charges,,,5214.19,,,percent of total billed charges,,,5214.19,,,percent of total billed charges,,,,,,,,,3655.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2607.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3072.2,,,percent of total billed charges,,
PACLITAXEL PROTEIN BND 100MG,2500019608,CDM,636,RC,J9264,HCPCS,6881713450,NDC,1712,APC,,outpatient,facility,100,GR,5214.19,5214.19,13,1908.39,,,,,,,,13.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,13.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.68,,,fee schedule,,,,,,,,,1908.39,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,13.54,,,fee schedule,,,,,,,,,,,,,,,14.22,,,fee schedule,,,14.22,,,fee schedule,,,,,,,,,13.54,,,fee schedule,,,13.54,,,fee schedule,,,14.22,,,fee schedule,,,,,,,,,,,,,,,20.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,13.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13,,,fee schedule,,,14.49,,,fee schedule,,,14.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.54,,,fee schedule,,,13.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,14.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,13.54,,,fee schedule,,,,,,,,,16.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,13.54,,,fee schedule,,,13.54,,,fee schedule,,,,,,,,,,,,,,,13.54,,,fee schedule,,,,,,,,,13.54,,,fee schedule,,,13.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.54,,,fee schedule,,,,,,,,,,,,,,,14.08,,,fee schedule,,,13.54,,,fee schedule,,,,,,,,,13.54,,,fee schedule,,,,,,,,,13.54,,,fee schedule,,,14.22,,,fee schedule,,,,,,,,
PACLITAXEL PROTEIN BND 100MG,2500019608,CDM,636,RC,J9264,HCPCS,6881713450,NDC,460,EAPG,,outpatient,facility,100,GR,5214.19,5214.19,1604.23,2422.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2422.39,,,fee schedule,,,1604.23,,,fee schedule,,,2153.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXMEDETOMIDINE INJ 200MCG/2ML,2500019609,CDM,250,RC,J3490,HCPCS,1672923993,NDC,,,,inpatient,facility,2,UN,75.6,75.6,6.05,75.6,,,,,,,,,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.6,,,percent of total billed charges,,,,,,,,,75.6,,,percent of total billed charges,,,38.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.36,,,percent of total billed charges,,,,,,,,,,,,,,,75.6,,,percent of total billed charges,,,64.26,,,percent of total billed charges,,,,,,,,,,,,,,,75.6,,,percent of total billed charges,,,40.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,6.05,,,percent of total billed charges,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.54,,,percent of total billed charges,,
DEXMEDETOMIDINE INJ 200MCG/2ML,2500019609,CDM,250,RC,J3490,HCPCS,1672923993,NDC,,,,outpatient,facility,2,UN,75.6,75.6,1.2,548.68,,53.61,,,percent of total billed charges,,,18.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,75.6,,,percent of total billed charges,,,47.38,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,53.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,53.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,27.67,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,75.6,,,fee schedule,,,75.6,,,percent of total billed charges,,,,,,,,,75.6,,,percent of total billed charges,,,46.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.86,,,percent of total billed charges,,,,,,,,,,,,,,,75.6,,,percent of total billed charges,,,75.6,,,percent of total billed charges,,,75.6,,,percent of total billed charges,,,,,,,,,44.6,,,percent of total billed charges,,,548.68,,,per diem,,,75.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,75.6,,,percent of total billed charges,,,64.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.15,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51,,,percent of total billed charges,,,61.18,,,percent of total billed charges,,,,,,,,,,,,,,,30.24,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,75.6,,,percent of total billed charges,,,75.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,75.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.05,,,percent of total billed charges,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,75.6,,,percent of total billed charges,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,56.7,,,percent of total billed charges,,,75.6,,,percent of total billed charges,,,75.6,,,percent of total billed charges,,,75.6,,,percent of total billed charges,,,,,,,,,53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,44.54,,,percent of total billed charges,,
DEXMEDETOMIDINE INJ 200MCG/2ML,2500019609,CDM,250,RC,J3490,HCPCS,1672923993,NDC,435,EAPG,,outpatient,facility,2,UN,75.6,75.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DULOXETINE HCL 30MG ORAL,2500019612,CDM,637,RC,1366811030,NDC,,,,,,inpatient,facility,30,UN,23.03,23.03,1.84,23.03,,,,,,,,,,,,,,23.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.03,,,percent of total billed charges,,,,,,,,,23.03,,,percent of total billed charges,,,11.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.82,,,percent of total billed charges,,,,,,,,,,,,,,,23.03,,,percent of total billed charges,,,19.58,,,percent of total billed charges,,,,,,,,,,,,,,,23.03,,,percent of total billed charges,,,12.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,23.03,,,percent of total billed charges,,,,,,,,,,,,,,,1.84,,,percent of total billed charges,,,23.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.57,,,percent of total billed charges,,
DULOXETINE HCL 30MG ORAL,2500019612,CDM,637,RC,1366811030,NDC,,,,,,outpatient,facility,30,UN,23.03,23.03,1.84,548.68,,16.33,,,percent of total billed charges,,,5.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,23.03,,,percent of total billed charges,,,14.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,16.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,16.19,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,23.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.43,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,23.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,23.03,,,fee schedule,,,23.03,,,percent of total billed charges,,,,,,,,,23.03,,,percent of total billed charges,,,14.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.41,,,percent of total billed charges,,,,,,,,,,,,,,,12.44,,,percent of total billed charges,,,11.98,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,,,,,,,13.59,,,percent of total billed charges,,,548.68,,,per diem,,,23.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,23.03,,,percent of total billed charges,,,19.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.23,,,percent of total billed charges,,,23.03,,,percent of total billed charges,,,23.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.54,,,percent of total billed charges,,,18.64,,,percent of total billed charges,,,,,,,,,,,,,,,9.21,,,percent of total billed charges,,,,,,,,,8.52,,,percent of total billed charges,,,8.52,,,percent of total billed charges,,,,,,,,,23.03,,,percent of total billed charges,,,23.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.84,,,percent of total billed charges,,,23.03,,,percent of total billed charges,,,,,,,,,,,,,,,23.03,,,percent of total billed charges,,,23.03,,,percent of total billed charges,,,,,,,,,21.42,,,percent of total billed charges,,,,,,,,,,,,,,,21.42,,,percent of total billed charges,,,21.42,,,percent of total billed charges,,,21.42,,,percent of total billed charges,,,17.27,,,percent of total billed charges,,,23.03,,,percent of total billed charges,,,23.03,,,percent of total billed charges,,,23.03,,,percent of total billed charges,,,,,,,,,16.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13.57,,,percent of total billed charges,,
DULOXETINE HCL 30MG ORAL,2500019612,CDM,637,RC,1366811030,NDC,999,EAPG,,,,outpatient,facility,30,UN,23.03,23.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREGABALIN 25 MG CAP,2500019634,CDM,637,RC,6923813109,NDC,,,,,,inpatient,facility,25,UN,27.81,27.81,2.22,27.81,,,,,,,,,,,,,,27.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.81,,,percent of total billed charges,,,,,,,,,27.81,,,percent of total billed charges,,,14.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.69,,,percent of total billed charges,,,,,,,,,,,,,,,27.81,,,percent of total billed charges,,,23.64,,,percent of total billed charges,,,,,,,,,,,,,,,27.81,,,percent of total billed charges,,,14.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,27.81,,,percent of total billed charges,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.39,,,percent of total billed charges,,
PREGABALIN 25 MG CAP,2500019634,CDM,637,RC,6923813109,NDC,,,,,,outpatient,facility,25,UN,27.81,27.81,2.22,548.68,,19.72,,,percent of total billed charges,,,6.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,27.81,,,percent of total billed charges,,,17.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,19.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,19.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,27.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,27.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,27.81,,,fee schedule,,,27.81,,,percent of total billed charges,,,,,,,,,27.81,,,percent of total billed charges,,,17.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.81,,,percent of total billed charges,,,,,,,,,,,,,,,15.02,,,percent of total billed charges,,,14.46,,,percent of total billed charges,,,15.3,,,percent of total billed charges,,,,,,,,,16.41,,,percent of total billed charges,,,548.68,,,per diem,,,27.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,27.81,,,percent of total billed charges,,,23.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.77,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.76,,,percent of total billed charges,,,22.5,,,percent of total billed charges,,,,,,,,,,,,,,,11.12,,,percent of total billed charges,,,,,,,,,10.29,,,percent of total billed charges,,,10.29,,,percent of total billed charges,,,,,,,,,27.81,,,percent of total billed charges,,,27.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.22,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,,,,,,,,,,,,,27.81,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,,,,,,,25.87,,,percent of total billed charges,,,,,,,,,,,,,,,25.87,,,percent of total billed charges,,,25.87,,,percent of total billed charges,,,25.87,,,percent of total billed charges,,,20.86,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,,,,,,,19.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,16.39,,,percent of total billed charges,,
PREGABALIN 25 MG CAP,2500019634,CDM,637,RC,6923813109,NDC,999,EAPG,,,,outpatient,facility,25,UN,27.81,27.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREGABALIN 50 MG CAP,2500019635,CDM,637,RC,904699261,NDC,,,,,,inpatient,facility,50,UN,2.48,2.48,0.2,2.48,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,2.48,,,percent of total billed charges,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.46,,,percent of total billed charges,,
PREGABALIN 50 MG CAP,2500019635,CDM,637,RC,904699261,NDC,,,,,,outpatient,facility,50,UN,2.48,2.48,0.2,548.68,,1.76,,,percent of total billed charges,,,0.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.48,,,percent of total billed charges,,,1.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.48,,,fee schedule,,,2.48,,,percent of total billed charges,,,,,,,,,2.48,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.77,,,percent of total billed charges,,,,,,,,,,,,,,,1.34,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,1.36,,,percent of total billed charges,,,,,,,,,1.46,,,percent of total billed charges,,,548.68,,,per diem,,,2.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.48,,,percent of total billed charges,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,2.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,2.48,,,percent of total billed charges,,,2.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,2.31,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,2.31,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,2.48,,,percent of total billed charges,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.46,,,percent of total billed charges,,
PREGABALIN 50 MG CAP,2500019635,CDM,637,RC,904699261,NDC,999,EAPG,,,,outpatient,facility,50,UN,2.48,2.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREGABALIN 100 MG,2500019637,CDM,637,RC,904700161,NDC,,,,,,inpatient,facility,100,UN,2.77,2.77,0.22,2.77,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,
PREGABALIN 100 MG,2500019637,CDM,637,RC,904700161,NDC,,,,,,outpatient,facility,100,UN,2.77,2.77,0.22,548.68,,1.96,,,percent of total billed charges,,,0.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.77,,,percent of total billed charges,,,1.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.77,,,fee schedule,,,2.77,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,1.63,,,percent of total billed charges,,,548.68,,,per diem,,,2.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.77,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.22,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,2.58,,,percent of total billed charges,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,2.58,,,percent of total billed charges,,,2.58,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.63,,,percent of total billed charges,,
PREGABALIN 100 MG,2500019637,CDM,637,RC,904700161,NDC,999,EAPG,,,,outpatient,facility,100,UN,2.77,2.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACAMPROSATE 333MG TABDR,2500019641,CDM,637,RC,6846243518,NDC,,,,,,inpatient,facility,333,UN,5.81,5.81,0.46,5.81,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,,,,,,,5.81,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.49,,,percent of total billed charges,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.42,,,percent of total billed charges,,
ACAMPROSATE 333MG TABDR,2500019641,CDM,637,RC,6846243518,NDC,,,,,,outpatient,facility,333,UN,5.81,5.81,0.46,548.68,,4.12,,,percent of total billed charges,,,1.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.81,,,percent of total billed charges,,,3.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.08,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.13,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.81,,,fee schedule,,,5.81,,,percent of total billed charges,,,,,,,,,5.81,,,percent of total billed charges,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.14,,,percent of total billed charges,,,,,,,,,,,,,,,3.14,,,percent of total billed charges,,,3.02,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,3.43,,,percent of total billed charges,,,548.68,,,per diem,,,5.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.81,,,percent of total billed charges,,,4.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.09,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,4.7,,,percent of total billed charges,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,,,,,,,2.15,,,percent of total billed charges,,,2.15,,,percent of total billed charges,,,,,,,,,5.81,,,percent of total billed charges,,,5.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,,,,,,,,,,,,,5.81,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,,,,,,,5.4,,,percent of total billed charges,,,,,,,,,,,,,,,5.4,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,4.36,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,5.81,,,percent of total billed charges,,,,,,,,,4.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.42,,,percent of total billed charges,,
ACAMPROSATE 333MG TABDR,2500019641,CDM,637,RC,6846243518,NDC,999,EAPG,,,,outpatient,facility,333,UN,5.81,5.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DULOXETINE HCL 20MG ORAL,2500019643,CDM,637,RC,7161040183,NDC,,,,,,inpatient,facility,20,UN,0.92,0.92,0.07,0.92,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,
DULOXETINE HCL 20MG ORAL,2500019643,CDM,637,RC,7161040183,NDC,,,,,,outpatient,facility,20,UN,0.92,0.92,0.07,548.68,,0.65,,,percent of total billed charges,,,0.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.92,,,percent of total billed charges,,,0.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.34,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.92,,,fee schedule,,,0.92,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,0.54,,,percent of total billed charges,,,548.68,,,per diem,,,0.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.92,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,0.34,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,0.86,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,0.92,,,percent of total billed charges,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.54,,,percent of total billed charges,,
DULOXETINE HCL 20MG ORAL,2500019643,CDM,637,RC,7161040183,NDC,999,EAPG,,,,outpatient,facility,20,UN,0.92,0.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BETAMETH AC NA PHOS 6 MG INJ,2500019651,CDM,636,RC,J0702,HCPCS,517072001,NDC,,,,inpatient,facility,1,ML,36.33,36.33,2.91,36.33,,,,,,,,,,,,,,36.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.33,,,percent of total billed charges,,,,,,,,,36.33,,,percent of total billed charges,,,18.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.8,,,percent of total billed charges,,,,,,,,,,,,,,,36.33,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,36.33,,,percent of total billed charges,,,19.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,36.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,36.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.41,,,percent of total billed charges,,
BETAMETH AC NA PHOS 6 MG INJ,2500019651,CDM,636,RC,J0702,HCPCS,517072001,NDC,,,,outpatient,facility,1,ML,36.33,36.33,2.91,548.68,,25.76,,,percent of total billed charges,,,8.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,36.33,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,36.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,13.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.3,,,fee schedule,,,36.33,,,fee schedule,,,36.33,,,percent of total billed charges,,,,,,,,,36.33,,,percent of total billed charges,,,22.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,21.43,,,percent of total billed charges,,,548.68,,,per diem,,,36.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,36.33,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.29,,,percent of total billed charges,,,36.33,,,percent of total billed charges,,,36.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.51,,,percent of total billed charges,,,29.4,,,percent of total billed charges,,,,,,,,,,,,,,,14.53,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,36.33,,,percent of total billed charges,,,36.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,36.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.91,,,percent of total billed charges,,,36.33,,,percent of total billed charges,,,,,,,,,,,,,,,36.33,,,percent of total billed charges,,,36.33,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,7.55,,,fee schedule,,,36.33,,,percent of total billed charges,,,36.33,,,percent of total billed charges,,,36.33,,,percent of total billed charges,,,,,,,,,25.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,21.41,,,percent of total billed charges,,
BETAMETH AC NA PHOS 6 MG INJ,2500019651,CDM,636,RC,J0702,HCPCS,517072001,NDC,496,EAPG,,outpatient,facility,1,ML,36.33,36.33,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFAZOLIN SOD 2 GM INJ,2500019654,CDM,636,RC,J0690,HCPCS,,,,,,inpatient,facility,20,GR,24.12,24.12,1.93,24.12,,,,,,,,,,,,,,24.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.12,,,percent of total billed charges,,,,,,,,,24.12,,,percent of total billed charges,,,12.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.47,,,percent of total billed charges,,,,,,,,,,,,,,,24.12,,,percent of total billed charges,,,20.5,,,percent of total billed charges,,,,,,,,,,,,,,,24.12,,,percent of total billed charges,,,12.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,24.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,24.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.21,,,percent of total billed charges,,
CEFAZOLIN SOD 2 GM INJ,2500019654,CDM,636,RC,J0690,HCPCS,,,,,,outpatient,facility,20,GR,24.12,24.12,0.71,548.68,,17.1,,,percent of total billed charges,,,5.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,24.12,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,24.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,8.83,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.71,,,fee schedule,,,24.12,,,fee schedule,,,24.12,,,percent of total billed charges,,,,,,,,,24.12,,,percent of total billed charges,,,14.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,14.23,,,percent of total billed charges,,,548.68,,,per diem,,,24.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,24.12,,,percent of total billed charges,,,20.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.81,,,percent of total billed charges,,,24.12,,,percent of total billed charges,,,24.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.27,,,percent of total billed charges,,,19.52,,,percent of total billed charges,,,,,,,,,,,,,,,9.65,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,24.12,,,percent of total billed charges,,,24.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.93,,,percent of total billed charges,,,24.12,,,percent of total billed charges,,,,,,,,,,,,,,,24.12,,,percent of total billed charges,,,24.12,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,24.12,,,percent of total billed charges,,,24.12,,,percent of total billed charges,,,24.12,,,percent of total billed charges,,,,,,,,,16.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.06,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.21,,,percent of total billed charges,,
CEFAZOLIN SOD 2 GM INJ,2500019654,CDM,636,RC,J0690,HCPCS,496,EAPG,,,,outpatient,facility,20,GR,24.12,24.12,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL 12 MCG TDSY,2500019657,CDM,637,RC,6050570802,NDC,,,,,,inpatient,facility,1,UN,66.99,66.99,5.36,66.99,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,66.99,,,percent of total billed charges,,,34.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,56.94,,,percent of total billed charges,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,35.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,,,,,,,5.36,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.47,,,percent of total billed charges,,
FENTANYL 12 MCG TDSY,2500019657,CDM,637,RC,6050570802,NDC,,,,,,outpatient,facility,1,UN,66.99,66.99,5.36,548.68,,47.5,,,percent of total billed charges,,,16.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,66.99,,,percent of total billed charges,,,41.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,47.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,47.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,24.52,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,66.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,66.99,,,fee schedule,,,66.99,,,percent of total billed charges,,,,,,,,,66.99,,,percent of total billed charges,,,41.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.73,,,percent of total billed charges,,,,,,,,,,,,,,,36.17,,,percent of total billed charges,,,34.83,,,percent of total billed charges,,,36.84,,,percent of total billed charges,,,,,,,,,39.52,,,percent of total billed charges,,,548.68,,,per diem,,,66.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,66.99,,,percent of total billed charges,,,56.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.58,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.19,,,percent of total billed charges,,,54.21,,,percent of total billed charges,,,,,,,,,,,,,,,26.8,,,percent of total billed charges,,,,,,,,,24.79,,,percent of total billed charges,,,24.79,,,percent of total billed charges,,,,,,,,,66.99,,,percent of total billed charges,,,66.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,66.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.36,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,,,,,,,62.31,,,percent of total billed charges,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,62.31,,,percent of total billed charges,,,62.31,,,percent of total billed charges,,,50.24,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,,,,,,,46.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,39.47,,,percent of total billed charges,,
FENTANYL 12 MCG TDSY,2500019657,CDM,637,RC,6050570802,NDC,999,EAPG,,,,outpatient,facility,1,UN,66.99,66.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL 2MCG/BUP 0.125 100ML,2500019659,CDM,636,RC,J3010,HCPCS,,,,,,inpatient,facility,100,UN,25.21,25.21,2.02,25.21,,,,,,,,,,,,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.21,,,percent of total billed charges,,,,,,,,,25.21,,,percent of total billed charges,,,12.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.13,,,percent of total billed charges,,,,,,,,,,,,,,,25.21,,,percent of total billed charges,,,21.43,,,percent of total billed charges,,,,,,,,,,,,,,,25.21,,,percent of total billed charges,,,13.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,
FENTANYL 2MCG/BUP 0.125 100ML,2500019659,CDM,636,RC,J3010,HCPCS,,,,,,outpatient,facility,100,UN,25.21,25.21,0.38,548.68,,17.88,,,percent of total billed charges,,,6.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,25.21,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.38,,,fee schedule,,,25.21,,,fee schedule,,,25.21,,,percent of total billed charges,,,,,,,,,25.21,,,percent of total billed charges,,,15.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,14.87,,,percent of total billed charges,,,548.68,,,per diem,,,25.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,25.21,,,percent of total billed charges,,,21.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.39,,,percent of total billed charges,,,25.21,,,percent of total billed charges,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.01,,,percent of total billed charges,,,20.4,,,percent of total billed charges,,,,,,,,,,,,,,,10.08,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,25.21,,,percent of total billed charges,,,25.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.02,,,percent of total billed charges,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,,25.21,,,percent of total billed charges,,,25.21,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.87,,,fee schedule,,,25.21,,,percent of total billed charges,,,25.21,,,percent of total billed charges,,,25.21,,,percent of total billed charges,,,,,,,,,17.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.85,,,percent of total billed charges,,
FENTANYL 2MCG/BUP 0.125 100ML,2500019659,CDM,636,RC,J3010,HCPCS,496,EAPG,,,,outpatient,facility,100,UN,25.21,25.21,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUTICASONE 220 MCG 12 GM INH,2500019672,CDM,637,RC,173072020,NDC,,,,,,inpatient,facility,1,UN,1403.59,1403.59,112.29,1403.59,,,,,,,,,,,,,,1403.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1403.59,,,percent of total billed charges,,,,,,,,,1403.59,,,percent of total billed charges,,,716.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1195.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,842.15,,,percent of total billed charges,,,,,,,,,,,,,,,1403.59,,,percent of total billed charges,,,1193.05,,,percent of total billed charges,,,,,,,,,,,,,,,1403.59,,,percent of total billed charges,,,745.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,561.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1403.59,,,percent of total billed charges,,,,,,,,,,,,,,,112.29,,,percent of total billed charges,,,1403.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1403.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,827,,,percent of total billed charges,,
FLUTICASONE 220 MCG 12 GM INH,2500019672,CDM,637,RC,173072020,NDC,,,,,,outpatient,facility,1,UN,1403.59,1403.59,112.29,1403.59,,995.29,,,percent of total billed charges,,,342.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1403.59,,,percent of total billed charges,,,879.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,986.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,986.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1403.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,513.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1403.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1403.59,,,fee schedule,,,1403.59,,,percent of total billed charges,,,,,,,,,1403.59,,,percent of total billed charges,,,860.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1000.06,,,percent of total billed charges,,,,,,,,,,,,,,,757.94,,,percent of total billed charges,,,729.87,,,percent of total billed charges,,,771.97,,,percent of total billed charges,,,,,,,,,828.12,,,percent of total billed charges,,,548.68,,,per diem,,,1403.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1403.59,,,percent of total billed charges,,,1193.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,745.45,,,percent of total billed charges,,,1403.59,,,percent of total billed charges,,,1403.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,946.86,,,percent of total billed charges,,,1135.79,,,percent of total billed charges,,,,,,,,,,,,,,,561.44,,,percent of total billed charges,,,,,,,,,519.33,,,percent of total billed charges,,,519.33,,,percent of total billed charges,,,,,,,,,1403.59,,,percent of total billed charges,,,1403.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1403.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,112.29,,,percent of total billed charges,,,1403.59,,,percent of total billed charges,,,,,,,,,,,,,,,1403.59,,,percent of total billed charges,,,1403.59,,,percent of total billed charges,,,,,,,,,1305.62,,,percent of total billed charges,,,,,,,,,,,,,,,1305.62,,,percent of total billed charges,,,1305.62,,,percent of total billed charges,,,1305.62,,,percent of total billed charges,,,1052.69,,,percent of total billed charges,,,1403.59,,,percent of total billed charges,,,1403.59,,,percent of total billed charges,,,1403.59,,,percent of total billed charges,,,,,,,,,984.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,701.79,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,827,,,percent of total billed charges,,
FLUTICASONE 220 MCG 12 GM INH,2500019672,CDM,637,RC,173072020,NDC,999,EAPG,,,,outpatient,facility,1,UN,1403.59,1403.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MORPHINE ORAL 20 MG/ML UD,2500019680,CDM,637,RC,54051744,NDC,,,,,,inpatient,facility,1,UN,2.77,2.77,0.22,2.77,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,
MORPHINE ORAL 20 MG/ML UD,2500019680,CDM,637,RC,54051744,NDC,,,,,,outpatient,facility,1,UN,2.77,2.77,0.22,548.68,,1.96,,,percent of total billed charges,,,0.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.77,,,percent of total billed charges,,,1.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.77,,,fee schedule,,,2.77,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.97,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,1.63,,,percent of total billed charges,,,548.68,,,per diem,,,2.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.77,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.87,,,percent of total billed charges,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,1.02,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,2.77,,,percent of total billed charges,,,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.22,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,2.58,,,percent of total billed charges,,,,,,,,,,,,,,,2.58,,,percent of total billed charges,,,2.58,,,percent of total billed charges,,,2.58,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,2.77,,,percent of total billed charges,,,,,,,,,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.63,,,percent of total billed charges,,
MORPHINE ORAL 20 MG/ML UD,2500019680,CDM,637,RC,54051744,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.77,2.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PANTOPRAZOLE 20MG TABEC,2500019694,CDM,637,RC,6586255990,NDC,,,,,,inpatient,facility,20,UN,17.39,17.39,1.39,17.39,,,,,,,,,,,,,,17.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.39,,,percent of total billed charges,,,,,,,,,17.39,,,percent of total billed charges,,,8.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.43,,,percent of total billed charges,,,,,,,,,,,,,,,17.39,,,percent of total billed charges,,,14.78,,,percent of total billed charges,,,,,,,,,,,,,,,17.39,,,percent of total billed charges,,,9.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,17.39,,,percent of total billed charges,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,17.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.25,,,percent of total billed charges,,
PANTOPRAZOLE 20MG TABEC,2500019694,CDM,637,RC,6586255990,NDC,,,,,,outpatient,facility,20,UN,17.39,17.39,1.39,548.68,,12.33,,,percent of total billed charges,,,4.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,17.39,,,percent of total billed charges,,,10.9,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,12.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,12.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,17.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,17.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,17.39,,,fee schedule,,,17.39,,,percent of total billed charges,,,,,,,,,17.39,,,percent of total billed charges,,,10.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.39,,,percent of total billed charges,,,,,,,,,,,,,,,9.39,,,percent of total billed charges,,,9.04,,,percent of total billed charges,,,9.56,,,percent of total billed charges,,,,,,,,,10.26,,,percent of total billed charges,,,548.68,,,per diem,,,17.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,17.39,,,percent of total billed charges,,,14.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,17.39,,,percent of total billed charges,,,17.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.73,,,percent of total billed charges,,,14.07,,,percent of total billed charges,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,6.43,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,17.39,,,percent of total billed charges,,,17.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.39,,,percent of total billed charges,,,17.39,,,percent of total billed charges,,,,,,,,,,,,,,,17.39,,,percent of total billed charges,,,17.39,,,percent of total billed charges,,,,,,,,,16.18,,,percent of total billed charges,,,,,,,,,,,,,,,16.18,,,percent of total billed charges,,,16.18,,,percent of total billed charges,,,16.18,,,percent of total billed charges,,,13.04,,,percent of total billed charges,,,17.39,,,percent of total billed charges,,,17.39,,,percent of total billed charges,,,17.39,,,percent of total billed charges,,,,,,,,,12.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.25,,,percent of total billed charges,,
PANTOPRAZOLE 20MG TABEC,2500019694,CDM,637,RC,6586255990,NDC,999,EAPG,,,,outpatient,facility,20,UN,17.39,17.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAMINOPHEN 160 MG/5 ML UDC,2500019704,CDM,637,RC,121065700,NDC,,,,,,inpatient,facility,5,UN,2.91,2.91,0.23,2.91,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,,,,,,,2.91,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,0.23,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,
ACETAMINOPHEN 160 MG/5 ML UDC,2500019704,CDM,637,RC,121065700,NDC,,,,,,outpatient,facility,5,UN,2.91,2.91,0.23,548.68,,2.06,,,percent of total billed charges,,,0.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.91,,,percent of total billed charges,,,1.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.07,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.91,,,fee schedule,,,2.91,,,percent of total billed charges,,,,,,,,,2.91,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,1.6,,,percent of total billed charges,,,,,,,,,1.72,,,percent of total billed charges,,,548.68,,,per diem,,,2.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.91,,,percent of total billed charges,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.55,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.16,,,percent of total billed charges,,,,,,,,,1.08,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,2.91,,,percent of total billed charges,,,2.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.23,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,2.71,,,percent of total billed charges,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,2.71,,,percent of total billed charges,,,2.71,,,percent of total billed charges,,,2.18,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.71,,,percent of total billed charges,,
ACETAMINOPHEN 160 MG/5 ML UDC,2500019704,CDM,637,RC,121065700,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.91,2.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMANTADINE 100 MG/10 ML UDC,2500019718,CDM,637,RC,121064610,NDC,,,,,,inpatient,facility,10,UN,14.22,14.22,1.14,14.22,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,,,,,,,14.22,,,percent of total billed charges,,,7.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.53,,,percent of total billed charges,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,12.09,,,percent of total billed charges,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,7.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.38,,,percent of total billed charges,,
AMANTADINE 100 MG/10 ML UDC,2500019718,CDM,637,RC,121064610,NDC,,,,,,outpatient,facility,10,UN,14.22,14.22,1.14,548.68,,10.08,,,percent of total billed charges,,,3.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.22,,,percent of total billed charges,,,8.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.2,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.22,,,fee schedule,,,14.22,,,percent of total billed charges,,,,,,,,,14.22,,,percent of total billed charges,,,8.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.13,,,percent of total billed charges,,,,,,,,,,,,,,,7.68,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,7.82,,,percent of total billed charges,,,,,,,,,8.39,,,percent of total billed charges,,,548.68,,,per diem,,,14.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.22,,,percent of total billed charges,,,12.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.55,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.59,,,percent of total billed charges,,,11.51,,,percent of total billed charges,,,,,,,,,,,,,,,5.69,,,percent of total billed charges,,,,,,,,,5.26,,,percent of total billed charges,,,5.26,,,percent of total billed charges,,,,,,,,,14.22,,,percent of total billed charges,,,14.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.14,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,,,,,,,,,,,,,14.22,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,,,,,,,13.23,,,percent of total billed charges,,,,,,,,,,,,,,,13.23,,,percent of total billed charges,,,13.23,,,percent of total billed charges,,,13.23,,,percent of total billed charges,,,10.67,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,14.22,,,percent of total billed charges,,,,,,,,,9.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.11,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.38,,,percent of total billed charges,,
AMANTADINE 100 MG/10 ML UDC,2500019718,CDM,637,RC,121064610,NDC,999,EAPG,,,,outpatient,facility,10,UN,14.22,14.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUDESONIDE 0.25 MG/2ML NEB SOL,2500019754,CDM,637,RC,J7626,HCPCS,93681555,NDC,,,,inpatient,facility,2,UN,31.05,31.05,2.48,31.05,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,,,,,,,31.05,,,percent of total billed charges,,,15.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.63,,,percent of total billed charges,,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,26.39,,,percent of total billed charges,,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,16.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,2.48,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.29,,,percent of total billed charges,,
BUDESONIDE 0.25 MG/2ML NEB SOL,2500019754,CDM,637,RC,J7626,HCPCS,93681555,NDC,,,,outpatient,facility,2,UN,31.05,31.05,0.66,548.68,,22.02,,,percent of total billed charges,,,7.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,31.05,,,percent of total billed charges,,,1.54,,,fee schedule,,,1.46,,,fee schedule,,,,,,,,,1.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.14,,,fee schedule,,,1.23,,,fee schedule,,,31.05,,,percent of total billed charges,,,,,,,,,31.05,,,percent of total billed charges,,,19.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.01,,,fee schedule,,,1.01,,,fee schedule,,,1.01,,,fee schedule,,,,,,,,,18.32,,,percent of total billed charges,,,548.68,,,per diem,,,31.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,31.05,,,percent of total billed charges,,,26.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.49,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.95,,,percent of total billed charges,,,25.13,,,percent of total billed charges,,,,,,,,,,,,,,,12.42,,,percent of total billed charges,,,,,,,,,2.36,,,fee schedule,,,1.7,,,fee schedule,,,,,,,,,31.05,,,percent of total billed charges,,,31.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.48,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,,,,,,,1.01,,,fee schedule,,,,,,,,,,,,,,,0.87,,,fee schedule,,,1.16,,,fee schedule,,,0.66,,,fee schedule,,,1.23,,,fee schedule,,,31.05,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,,,,,,,21.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.29,,,percent of total billed charges,,
BUDESONIDE 0.25 MG/2ML NEB SOL,2500019754,CDM,637,RC,J7626,HCPCS,93681555,NDC,496,EAPG,,outpatient,facility,2,UN,31.05,31.05,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE 0.5 50 ML INJ,2500019758,CDM,250,RC,J3490,HCPCS,409116301,NDC,,,,inpatient,facility,50,UN,8.91,8.91,0.71,8.91,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,8.91,,,percent of total billed charges,,,4.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.35,,,percent of total billed charges,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,7.57,,,percent of total billed charges,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,4.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.25,,,percent of total billed charges,,
BUPIVACAINE 0.5 50 ML INJ,2500019758,CDM,250,RC,J3490,HCPCS,409116301,NDC,,,,outpatient,facility,50,UN,8.91,8.91,0.71,548.68,,6.32,,,percent of total billed charges,,,2.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.91,,,percent of total billed charges,,,5.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.26,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.26,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,8.91,,,fee schedule,,,8.91,,,percent of total billed charges,,,,,,,,,8.91,,,percent of total billed charges,,,5.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.35,,,percent of total billed charges,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,,,,,,,5.26,,,percent of total billed charges,,,548.68,,,per diem,,,8.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.91,,,percent of total billed charges,,,7.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.73,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.01,,,percent of total billed charges,,,7.21,,,percent of total billed charges,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,8.91,,,percent of total billed charges,,,8.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.71,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,,8.91,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,6.68,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,,,,,,,6.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.25,,,percent of total billed charges,,
BUPIVACAINE 0.5 50 ML INJ,2500019758,CDM,250,RC,J3490,HCPCS,409116301,NDC,435,EAPG,,outpatient,facility,50,UN,8.91,8.91,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE/EPI 0.2550 ML INJ,2500019766,CDM,250,RC,J3490,HCPCS,6332346157,NDC,,,,inpatient,facility,50,UN,56.17,56.17,4.49,56.17,,,,,,,,,,,,,,56.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.17,,,percent of total billed charges,,,,,,,,,56.17,,,percent of total billed charges,,,28.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.7,,,percent of total billed charges,,,,,,,,,,,,,,,56.17,,,percent of total billed charges,,,47.74,,,percent of total billed charges,,,,,,,,,,,,,,,56.17,,,percent of total billed charges,,,29.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,56.17,,,percent of total billed charges,,,,,,,,,,,,,,,4.49,,,percent of total billed charges,,,56.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.1,,,percent of total billed charges,,
BUPIVACAINE/EPI 0.2550 ML INJ,2500019766,CDM,250,RC,J3490,HCPCS,6332346157,NDC,,,,outpatient,facility,50,UN,56.17,56.17,1.2,548.68,,39.83,,,percent of total billed charges,,,13.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,56.17,,,percent of total billed charges,,,35.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,39.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,39.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,56.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,20.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,56.17,,,fee schedule,,,56.17,,,percent of total billed charges,,,,,,,,,56.17,,,percent of total billed charges,,,34.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.02,,,percent of total billed charges,,,,,,,,,,,,,,,56.17,,,percent of total billed charges,,,56.17,,,percent of total billed charges,,,56.17,,,percent of total billed charges,,,,,,,,,33.14,,,percent of total billed charges,,,548.68,,,per diem,,,56.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,56.17,,,percent of total billed charges,,,47.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.83,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.89,,,percent of total billed charges,,,45.45,,,percent of total billed charges,,,,,,,,,,,,,,,22.47,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,56.17,,,percent of total billed charges,,,56.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,56.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.49,,,percent of total billed charges,,,56.17,,,percent of total billed charges,,,,,,,,,,,,,,,56.17,,,percent of total billed charges,,,56.17,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,42.13,,,percent of total billed charges,,,56.17,,,percent of total billed charges,,,56.17,,,percent of total billed charges,,,56.17,,,percent of total billed charges,,,,,,,,,39.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,33.1,,,percent of total billed charges,,
BUPIVACAINE/EPI 0.2550 ML INJ,2500019766,CDM,250,RC,J3490,HCPCS,6332346157,NDC,435,EAPG,,outpatient,facility,50,UN,56.17,56.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHLORPROMAZINE 25 MG/ML INJ,2500019806,CDM,636,RC,J3230,HCPCS,641139735,NDC,,,,inpatient,facility,1,UN,95.34,95.34,7.63,95.34,,,,,,,,,,,,,,95.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.34,,,percent of total billed charges,,,,,,,,,95.34,,,percent of total billed charges,,,48.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.2,,,percent of total billed charges,,,,,,,,,,,,,,,95.34,,,percent of total billed charges,,,81.04,,,percent of total billed charges,,,,,,,,,,,,,,,95.34,,,percent of total billed charges,,,50.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,95.34,,,percent of total billed charges,,,,,,,,,,,,,,,7.63,,,percent of total billed charges,,,95.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.17,,,percent of total billed charges,,
CHLORPROMAZINE 25 MG/ML INJ,2500019806,CDM,636,RC,J3230,HCPCS,641139735,NDC,,,,outpatient,facility,1,UN,95.34,95.34,7.63,548.68,,67.61,,,percent of total billed charges,,,23.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,95.34,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,95.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,34.89,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.31,,,fee schedule,,,95.34,,,fee schedule,,,95.34,,,percent of total billed charges,,,,,,,,,95.34,,,percent of total billed charges,,,58.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,56.25,,,percent of total billed charges,,,548.68,,,per diem,,,95.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,95.34,,,percent of total billed charges,,,81.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.64,,,percent of total billed charges,,,95.34,,,percent of total billed charges,,,95.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.32,,,percent of total billed charges,,,77.15,,,percent of total billed charges,,,,,,,,,,,,,,,38.14,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,95.34,,,percent of total billed charges,,,95.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,95.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.63,,,percent of total billed charges,,,95.34,,,percent of total billed charges,,,,,,,,,,,,,,,95.34,,,percent of total billed charges,,,95.34,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,31.23,,,fee schedule,,,95.34,,,percent of total billed charges,,,95.34,,,percent of total billed charges,,,95.34,,,percent of total billed charges,,,,,,,,,66.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.67,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,56.17,,,percent of total billed charges,,
CHLORPROMAZINE 25 MG/ML INJ,2500019806,CDM,636,RC,J3230,HCPCS,641139735,NDC,435,EAPG,,outpatient,facility,1,UN,95.34,95.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMPHETAMINES (MIXED) 10 MG CAP,2500019820,CDM,637,RC,5766433788,NDC,,,,,,inpatient,facility,10,UN,3.63,3.63,0.29,3.63,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,,,,,,,3.63,,,percent of total billed charges,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.18,,,percent of total billed charges,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,
AMPHETAMINES (MIXED) 10 MG CAP,2500019820,CDM,637,RC,5766433788,NDC,,,,,,outpatient,facility,10,UN,3.63,3.63,0.29,548.68,,2.57,,,percent of total billed charges,,,0.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.63,,,percent of total billed charges,,,2.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.33,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.63,,,fee schedule,,,3.63,,,percent of total billed charges,,,,,,,,,3.63,,,percent of total billed charges,,,2.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,1.96,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,2.14,,,percent of total billed charges,,,548.68,,,per diem,,,3.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.63,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,1.34,,,percent of total billed charges,,,1.34,,,percent of total billed charges,,,,,,,,,3.63,,,percent of total billed charges,,,3.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.29,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,3.38,,,percent of total billed charges,,,3.38,,,percent of total billed charges,,,2.72,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,3.63,,,percent of total billed charges,,,,,,,,,2.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.14,,,percent of total billed charges,,
AMPHETAMINES (MIXED) 10 MG CAP,2500019820,CDM,637,RC,5766433788,NDC,999,EAPG,,,,outpatient,facility,10,UN,3.63,3.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIGECYCLINE 50 MG INJ,2500019822,CDM,636,RC,J3243,HCPCS,1672936468,NDC,,,,inpatient,facility,50,GR,557.7,557.7,44.62,557.7,,,,,,,,,,,,,,557.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.7,,,percent of total billed charges,,,,,,,,,557.7,,,percent of total billed charges,,,284.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,474.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.62,,,percent of total billed charges,,,,,,,,,,,,,,,557.7,,,percent of total billed charges,,,474.04,,,percent of total billed charges,,,,,,,,,,,,,,,557.7,,,percent of total billed charges,,,296.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,557.7,,,percent of total billed charges,,,,,,,,,,,,,,,44.62,,,percent of total billed charges,,,557.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,557.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.6,,,percent of total billed charges,,
TIGECYCLINE 50 MG INJ,2500019822,CDM,636,RC,J3243,HCPCS,1672936468,NDC,,,,outpatient,facility,50,GR,557.7,557.7,0.61,557.7,,395.47,,,percent of total billed charges,,,136.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,557.7,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,557.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,204.12,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.52,,,fee schedule,,,557.7,,,fee schedule,,,557.7,,,percent of total billed charges,,,,,,,,,557.7,,,percent of total billed charges,,,341.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.74,,,fee schedule,,,0.74,,,fee schedule,,,0.74,,,fee schedule,,,,,,,,,329.04,,,percent of total billed charges,,,548.68,,,per diem,,,557.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,557.7,,,percent of total billed charges,,,474.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,296.19,,,percent of total billed charges,,,557.7,,,percent of total billed charges,,,557.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,376.22,,,percent of total billed charges,,,451.29,,,percent of total billed charges,,,,,,,,,,,,,,,223.08,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,557.7,,,percent of total billed charges,,,557.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,557.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,44.62,,,percent of total billed charges,,,557.7,,,percent of total billed charges,,,,,,,,,,,,,,,557.7,,,percent of total billed charges,,,557.7,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.61,,,fee schedule,,,557.7,,,percent of total billed charges,,,557.7,,,percent of total billed charges,,,557.7,,,percent of total billed charges,,,,,,,,,391,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,328.6,,,percent of total billed charges,,
TIGECYCLINE 50 MG INJ,2500019822,CDM,636,RC,J3243,HCPCS,1672936468,NDC,435,EAPG,,outpatient,facility,50,GR,557.7,557.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DECITABINE 50 MG VIAL,2500019824,CDM,636,RC,J0894,HCPCS,1672922405,NDC,,,,inpatient,facility,50,GR,6436.78,6436.78,514.94,6436.78,,,,,,,,,,,,,,6436.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6436.78,,,percent of total billed charges,,,,,,,,,6436.78,,,percent of total billed charges,,,3286.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5482.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3862.07,,,percent of total billed charges,,,,,,,,,,,,,,,6436.78,,,percent of total billed charges,,,5471.26,,,percent of total billed charges,,,,,,,,,,,,,,,6436.78,,,percent of total billed charges,,,3418.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2574.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6436.78,,,percent of total billed charges,,,,,,,,,,,,,,,514.94,,,percent of total billed charges,,,6436.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6436.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3792.55,,,percent of total billed charges,,
DECITABINE 50 MG VIAL,2500019824,CDM,636,RC,J0894,HCPCS,1672922405,NDC,,,,outpatient,facility,50,GR,6436.78,6436.78,1.49,6436.78,,1.64,,,fee schedule,,,1570.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6436.78,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,6436.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2355.86,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6436.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6436.78,,,fee schedule,,,6436.78,,,percent of total billed charges,,,,,,,,,6436.78,,,percent of total billed charges,,,3945.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4586.21,,,percent of total billed charges,,,,,,,,,,,,,,,1.69,,,fee schedule,,,1.69,,,fee schedule,,,1.69,,,fee schedule,,,,,,,,,3797.7,,,percent of total billed charges,,,548.68,,,per diem,,,6436.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6436.78,,,percent of total billed charges,,,5471.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3418.57,,,percent of total billed charges,,,6436.78,,,percent of total billed charges,,,6436.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4342.25,,,percent of total billed charges,,,5208.64,,,percent of total billed charges,,,,,,,,,,,,,,,2574.71,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,6436.78,,,percent of total billed charges,,,6436.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6436.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,514.94,,,percent of total billed charges,,,6436.78,,,percent of total billed charges,,,,,,,,,,,,,,,6436.78,,,percent of total billed charges,,,6436.78,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1.49,,,fee schedule,,,6436.78,,,percent of total billed charges,,,6436.78,,,percent of total billed charges,,,6436.78,,,percent of total billed charges,,,,,,,,,4512.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3218.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3792.55,,,percent of total billed charges,,
DECITABINE 50 MG VIAL,2500019824,CDM,636,RC,J0894,HCPCS,1672922405,NDC,431,EAPG,,outpatient,facility,50,GR,6436.78,6436.78,42.81,64.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.64,,,fee schedule,,,42.81,,,fee schedule,,,57.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.81,,,fee schedule,,,42.81,,,fee schedule,,,42.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,42.81,,,fee schedule,,,,,,,,,,,,,,,42.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSULIN LISPRO MIX 75/25 1UNIT,2500019828,CDM,637,RC,J1815,HCPCS,2751101,NDC,,,,inpatient,facility,0.01,UN,1.12,1.12,0.09,1.12,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,1.12,,,percent of total billed charges,,,0.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,
INSULIN LISPRO MIX 75/25 1UNIT,2500019828,CDM,637,RC,J1815,HCPCS,2751101,NDC,,,,outpatient,facility,0.01,UN,1.12,1.12,0.09,548.68,,0.79,,,percent of total billed charges,,,0.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.12,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.41,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.12,,,fee schedule,,,1.12,,,percent of total billed charges,,,,,,,,,1.12,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,0.66,,,percent of total billed charges,,,548.68,,,per diem,,,1.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.12,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1.12,,,percent of total billed charges,,,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.94,,,fee schedule,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.66,,,percent of total billed charges,,
INSULIN LISPRO MIX 75/25 1UNIT,2500019828,CDM,637,RC,J1815,HCPCS,2751101,NDC,496,EAPG,,outpatient,facility,0.01,UN,1.12,1.12,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CINACALCET 30 MG TAB,2500019830,CDM,637,RC,J0604,HCPCS,7043600704,NDC,,,,inpatient,facility,30,UN,102.03,102.03,8.16,102.03,,,,,,,,,,,,,,102.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.03,,,percent of total billed charges,,,,,,,,,102.03,,,percent of total billed charges,,,52.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.22,,,percent of total billed charges,,,,,,,,,,,,,,,102.03,,,percent of total billed charges,,,86.73,,,percent of total billed charges,,,,,,,,,,,,,,,102.03,,,percent of total billed charges,,,54.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,102.03,,,percent of total billed charges,,,,,,,,,,,,,,,8.16,,,percent of total billed charges,,,102.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,102.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.12,,,percent of total billed charges,,
CINACALCET 30 MG TAB,2500019830,CDM,637,RC,J0604,HCPCS,7043600704,NDC,,,,outpatient,facility,30,UN,102.03,102.03,0.02,548.68,,72.35,,,percent of total billed charges,,,24.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,102.03,,,percent of total billed charges,,,0.03,,,fee schedule,,,0.02,,,fee schedule,,,,,,,,,0.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,102.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,37.34,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,102.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,102.03,,,fee schedule,,,102.03,,,percent of total billed charges,,,,,,,,,102.03,,,percent of total billed charges,,,62.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.7,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,fee schedule,,,0.03,,,fee schedule,,,0.03,,,fee schedule,,,,,,,,,60.2,,,percent of total billed charges,,,548.68,,,per diem,,,102.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,102.03,,,percent of total billed charges,,,86.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.19,,,percent of total billed charges,,,102.03,,,percent of total billed charges,,,102.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.83,,,percent of total billed charges,,,82.56,,,percent of total billed charges,,,,,,,,,,,,,,,40.81,,,percent of total billed charges,,,,,,,,,2.01,,,fee schedule,,,1.45,,,fee schedule,,,,,,,,,102.03,,,percent of total billed charges,,,102.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,102.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.16,,,percent of total billed charges,,,102.03,,,percent of total billed charges,,,,,,,,,,,,,,,102.03,,,percent of total billed charges,,,102.03,,,percent of total billed charges,,,,,,,,,0.86,,,fee schedule,,,,,,,,,,,,,,,0.74,,,fee schedule,,,0.99,,,fee schedule,,,0.56,,,fee schedule,,,76.52,,,percent of total billed charges,,,102.03,,,percent of total billed charges,,,102.03,,,percent of total billed charges,,,102.03,,,percent of total billed charges,,,,,,,,,71.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,60.12,,,percent of total billed charges,,
CINACALCET 30 MG TAB,2500019830,CDM,637,RC,J0604,HCPCS,7043600704,NDC,436,EAPG,,outpatient,facility,30,UN,102.03,102.03,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 2  EPI 1.8 ML DENTAL,2500019853,CDM,637,RC,409726301,NDC,,,,,,inpatient,facility,1.8,UN,1.29,1.29,0.1,1.29,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,
LIDOCAINE 2  EPI 1.8 ML DENTAL,2500019853,CDM,637,RC,409726301,NDC,,,,,,outpatient,facility,1.8,UN,1.29,1.29,0.1,548.68,,0.91,,,percent of total billed charges,,,0.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.29,,,percent of total billed charges,,,0.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.47,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.29,,,fee schedule,,,1.29,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,0.76,,,percent of total billed charges,,,548.68,,,per diem,,,1.29,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.29,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,0.48,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,1.29,,,percent of total billed charges,,,1.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,,,,,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,1.2,,,percent of total billed charges,,,0.97,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,1.29,,,percent of total billed charges,,,,,,,,,0.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.76,,,percent of total billed charges,,
LIDOCAINE 2  EPI 1.8 ML DENTAL,2500019853,CDM,637,RC,409726301,NDC,999,EAPG,,,,outpatient,facility,1.8,UN,1.29,1.29,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PANITUMUMAB 100 MG INJ,2500019858,CDM,636,RC,J9303,HCPCS,5551395401,NDC,,,,inpatient,facility,5,ML,5693.75,5693.75,455.5,5693.75,,,,,,,,,,,,,,5693.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5693.75,,,percent of total billed charges,,,,,,,,,5693.75,,,percent of total billed charges,,,2907.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4849.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3416.25,,,percent of total billed charges,,,,,,,,,,,,,,,5693.75,,,percent of total billed charges,,,4839.69,,,percent of total billed charges,,,,,,,,,,,,,,,5693.75,,,percent of total billed charges,,,3023.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2277.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5693.75,,,percent of total billed charges,,,,,,,,,,,,,,,455.5,,,percent of total billed charges,,,5693.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5693.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3354.76,,,percent of total billed charges,,
PANITUMUMAB 100 MG INJ,2500019858,CDM,636,RC,J9303,HCPCS,5551395401,NDC,,,,outpatient,facility,5,ML,5693.75,5693.75,95.32,5693.75,,4037.44,,,percent of total billed charges,,,,,,,,,5693.75,,,percent of total billed charges,,,205.98,,,fee schedule,,,194.87,,,fee schedule,,,,,,,,,194.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,5693.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5693.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5693.75,,,fee schedule,,,5693.75,,,percent of total billed charges,,,,,,,,,5693.75,,,percent of total billed charges,,,3489.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4056.8,,,percent of total billed charges,,,,,,,,,,,,,,,150.66,,,fee schedule,,,150.66,,,fee schedule,,,150.66,,,fee schedule,,,,,,,,,3359.31,,,percent of total billed charges,,,548.68,,,per diem,,,5693.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5693.75,,,percent of total billed charges,,,4839.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3023.95,,,percent of total billed charges,,,5693.75,,,percent of total billed charges,,,5693.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3841,,,percent of total billed charges,,,4607.38,,,percent of total billed charges,,,,,,,,,,,,,,,2277.5,,,percent of total billed charges,,,,,,,,,343.17,,,fee schedule,,,246.94,,,fee schedule,,,,,,,,,5693.75,,,percent of total billed charges,,,,,,,,,,,,,,,455.5,,,percent of total billed charges,,,5693.75,,,percent of total billed charges,,,,,,,,,,,,,,,5693.75,,,percent of total billed charges,,,5693.75,,,percent of total billed charges,,,,,,,,,146.65,,,fee schedule,,,,,,,,,,,,,,,127.11,,,fee schedule,,,169.48,,,fee schedule,,,95.32,,,fee schedule,,,164.67,,,fee schedule,,,5693.75,,,percent of total billed charges,,,5693.75,,,percent of total billed charges,,,5693.75,,,percent of total billed charges,,,,,,,,,3991.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2846.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3354.76,,,percent of total billed charges,,
PANITUMUMAB 100 MG INJ,2500019858,CDM,636,RC,J9303,HCPCS,5551395401,NDC,9235,APC,,outpatient,facility,5,ML,5693.75,5693.75,159.08,2083.91,,,,,,,,170.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,165.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.37,,,fee schedule,,,,,,,,,2083.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,165.71,,,fee schedule,,,,,,,,,,,,,,,174,,,fee schedule,,,174,,,fee schedule,,,,,,,,,165.71,,,fee schedule,,,165.71,,,fee schedule,,,174,,,fee schedule,,,,,,,,,,,,,,,248.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,165.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.08,,,fee schedule,,,177.31,,,fee schedule,,,174,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.71,,,fee schedule,,,165.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,172.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,165.71,,,fee schedule,,,,,,,,,207.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,207.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,165.71,,,fee schedule,,,165.71,,,fee schedule,,,,,,,,,,,,,,,165.71,,,fee schedule,,,,,,,,,165.71,,,fee schedule,,,170.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.71,,,fee schedule,,,,,,,,,,,,,,,172.34,,,fee schedule,,,165.71,,,fee schedule,,,,,,,,,165.71,,,fee schedule,,,,,,,,,165.71,,,fee schedule,,,174,,,fee schedule,,,,,,,,
PANITUMUMAB 100 MG INJ,2500019858,CDM,636,RC,J9303,HCPCS,5551395401,NDC,462,EAPG,,outpatient,facility,5,ML,5693.75,5693.75,4530.01,6840.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6840.32,,,fee schedule,,,4530.01,,,fee schedule,,,6081.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PANITUMUMAB 400 MG INJ,2500019860,CDM,636,RC,J9303,HCPCS,5551395601,NDC,,,,inpatient,facility,20,ML,22775.02,22775.02,1822,22775.02,,,,,,,,,,,,,,22775.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22775.02,,,percent of total billed charges,,,,,,,,,22775.02,,,percent of total billed charges,,,11628.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19397.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13665.01,,,percent of total billed charges,,,,,,,,,,,,,,,22775.02,,,percent of total billed charges,,,19358.77,,,percent of total billed charges,,,,,,,,,,,,,,,22775.02,,,percent of total billed charges,,,12095.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9110.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,22775.02,,,percent of total billed charges,,,,,,,,,,,,,,,1822,,,percent of total billed charges,,,22775.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22775.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13419.04,,,percent of total billed charges,,
PANITUMUMAB 400 MG INJ,2500019860,CDM,636,RC,J9303,HCPCS,5551395601,NDC,,,,outpatient,facility,20,ML,22775.02,22775.02,95.32,22775.02,,16149.77,,,percent of total billed charges,,,,,,,,,22775.02,,,percent of total billed charges,,,205.98,,,fee schedule,,,194.87,,,fee schedule,,,,,,,,,194.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,22775.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,22775.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,22775.02,,,fee schedule,,,22775.02,,,percent of total billed charges,,,,,,,,,22775.02,,,percent of total billed charges,,,13958.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16227.2,,,percent of total billed charges,,,,,,,,,,,,,,,150.66,,,fee schedule,,,150.66,,,fee schedule,,,150.66,,,fee schedule,,,,,,,,,13437.26,,,percent of total billed charges,,,548.68,,,per diem,,,22775.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,22775.02,,,percent of total billed charges,,,19358.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12095.81,,,percent of total billed charges,,,22775.02,,,percent of total billed charges,,,22775.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15364.03,,,percent of total billed charges,,,18429.55,,,percent of total billed charges,,,,,,,,,,,,,,,9110.01,,,percent of total billed charges,,,,,,,,,343.17,,,fee schedule,,,246.94,,,fee schedule,,,,,,,,,22775.02,,,percent of total billed charges,,,,,,,,,,,,,,,1822,,,percent of total billed charges,,,22775.02,,,percent of total billed charges,,,,,,,,,,,,,,,22775.02,,,percent of total billed charges,,,22775.02,,,percent of total billed charges,,,,,,,,,146.65,,,fee schedule,,,,,,,,,,,,,,,127.11,,,fee schedule,,,169.48,,,fee schedule,,,95.32,,,fee schedule,,,164.67,,,fee schedule,,,22775.02,,,percent of total billed charges,,,22775.02,,,percent of total billed charges,,,22775.02,,,percent of total billed charges,,,,,,,,,15967.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11387.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,13419.04,,,percent of total billed charges,,
PANITUMUMAB 400 MG INJ,2500019860,CDM,636,RC,J9303,HCPCS,5551395601,NDC,9235,APC,,outpatient,facility,20,ML,22775.02,22775.02,159.08,8335.66,,,,,,,,170.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,165.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.37,,,fee schedule,,,,,,,,,8335.66,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,165.71,,,fee schedule,,,,,,,,,,,,,,,174,,,fee schedule,,,174,,,fee schedule,,,,,,,,,165.71,,,fee schedule,,,165.71,,,fee schedule,,,174,,,fee schedule,,,,,,,,,,,,,,,248.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,165.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.08,,,fee schedule,,,177.31,,,fee schedule,,,174,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.71,,,fee schedule,,,165.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,172.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,165.71,,,fee schedule,,,,,,,,,207.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,207.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,165.71,,,fee schedule,,,165.71,,,fee schedule,,,,,,,,,,,,,,,165.71,,,fee schedule,,,,,,,,,165.71,,,fee schedule,,,170.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.71,,,fee schedule,,,,,,,,,,,,,,,172.34,,,fee schedule,,,165.71,,,fee schedule,,,,,,,,,165.71,,,fee schedule,,,,,,,,,165.71,,,fee schedule,,,174,,,fee schedule,,,,,,,,
PANITUMUMAB 400 MG INJ,2500019860,CDM,636,RC,J9303,HCPCS,5551395601,NDC,462,EAPG,,outpatient,facility,20,ML,22775.02,22775.02,4530.01,6840.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6840.32,,,fee schedule,,,4530.01,,,fee schedule,,,6081.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SODIUM CHLORIDE 0.9  NEB 5 ML,2500019868,CDM,637,RC,378698601,NDC,,,,,,inpatient,facility,5,UN,1.19,1.19,0.1,1.19,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,1.19,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,0.1,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,
SODIUM CHLORIDE 0.9  NEB 5 ML,2500019868,CDM,637,RC,378698601,NDC,,,,,,outpatient,facility,5,UN,1.19,1.19,0.1,548.68,,0.84,,,percent of total billed charges,,,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.19,,,percent of total billed charges,,,0.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.19,,,fee schedule,,,1.19,,,percent of total billed charges,,,,,,,,,1.19,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,0.62,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,0.7,,,percent of total billed charges,,,548.68,,,per diem,,,1.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.19,,,percent of total billed charges,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,0.44,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,1.19,,,percent of total billed charges,,,1.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.1,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,1.11,,,percent of total billed charges,,,,,,,,,,,,,,,1.11,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,1.11,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,1.19,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.7,,,percent of total billed charges,,
SODIUM CHLORIDE 0.9  NEB 5 ML,2500019868,CDM,637,RC,378698601,NDC,999,EAPG,,,,outpatient,facility,5,UN,1.19,1.19,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ARSENIC TRIOXIDE 10MG/10ML AMP,2500019895,CDM,636,RC,J9017,HCPCS,6838299710,NDC,,,,inpatient,facility,10,GR,1250.86,1250.86,100.07,1250.86,,,,,,,,,,,,,,1250.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1250.86,,,percent of total billed charges,,,,,,,,,1250.86,,,percent of total billed charges,,,638.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1065.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,750.52,,,percent of total billed charges,,,,,,,,,,,,,,,1250.86,,,percent of total billed charges,,,1063.23,,,percent of total billed charges,,,,,,,,,,,,,,,1250.86,,,percent of total billed charges,,,664.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1250.86,,,percent of total billed charges,,,,,,,,,,,,,,,100.07,,,percent of total billed charges,,,1250.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1250.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,737.01,,,percent of total billed charges,,
ARSENIC TRIOXIDE 10MG/10ML AMP,2500019895,CDM,636,RC,J9017,HCPCS,6838299710,NDC,,,,outpatient,facility,10,GR,1250.86,1250.86,10.49,1250.86,,11.9,,,fee schedule,,,,,,,,,1250.86,,,percent of total billed charges,,,13.88,,,fee schedule,,,13.13,,,fee schedule,,,,,,,,,13.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1250.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1250.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1250.86,,,fee schedule,,,1250.86,,,percent of total billed charges,,,,,,,,,1250.86,,,percent of total billed charges,,,766.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,891.24,,,percent of total billed charges,,,,,,,,,,,,,,,15.78,,,fee schedule,,,15.78,,,fee schedule,,,15.78,,,fee schedule,,,,,,,,,738.01,,,percent of total billed charges,,,548.68,,,per diem,,,1250.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1250.86,,,percent of total billed charges,,,1063.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,664.33,,,percent of total billed charges,,,1250.86,,,percent of total billed charges,,,1250.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,843.83,,,percent of total billed charges,,,1012.2,,,percent of total billed charges,,,,,,,,,,,,,,,500.34,,,percent of total billed charges,,,,,,,,,37.76,,,fee schedule,,,27.17,,,fee schedule,,,,,,,,,1250.86,,,percent of total billed charges,,,,,,,,,,,,,,,100.07,,,percent of total billed charges,,,1250.86,,,percent of total billed charges,,,,,,,,,,,,,,,1250.86,,,percent of total billed charges,,,1250.86,,,percent of total billed charges,,,,,,,,,16.14,,,fee schedule,,,,,,,,,,,,,,,13.99,,,fee schedule,,,18.65,,,fee schedule,,,10.49,,,fee schedule,,,11.09,,,fee schedule,,,1250.86,,,percent of total billed charges,,,1250.86,,,percent of total billed charges,,,1250.86,,,percent of total billed charges,,,,,,,,,876.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,625.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,737.01,,,percent of total billed charges,,
ARSENIC TRIOXIDE 10MG/10ML AMP,2500019895,CDM,636,RC,J9017,HCPCS,6838299710,NDC,9012,APC,,outpatient,facility,10,GR,1250.86,1250.86,4.49,457.81,,,,,,,,4.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,4.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.73,,,fee schedule,,,,,,,,,457.81,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,fee schedule,,,,,,,,,,,,,,,4.91,,,fee schedule,,,4.91,,,fee schedule,,,,,,,,,4.68,,,fee schedule,,,4.68,,,fee schedule,,,4.91,,,fee schedule,,,,,,,,,,,,,,,7.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,4.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.49,,,fee schedule,,,5.01,,,fee schedule,,,4.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,fee schedule,,,4.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,4.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,fee schedule,,,,,,,,,5.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,4.68,,,fee schedule,,,4.68,,,fee schedule,,,,,,,,,,,,,,,4.68,,,fee schedule,,,,,,,,,4.68,,,fee schedule,,,4.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,fee schedule,,,,,,,,,,,,,,,4.87,,,fee schedule,,,4.68,,,fee schedule,,,,,,,,,4.68,,,fee schedule,,,,,,,,,4.68,,,fee schedule,,,4.91,,,fee schedule,,,,,,,,
ARSENIC TRIOXIDE 10MG/10ML AMP,2500019895,CDM,636,RC,J9017,HCPCS,6838299710,NDC,432,EAPG,,outpatient,facility,10,GR,1250.86,1250.86,148.29,223.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.92,,,fee schedule,,,148.29,,,fee schedule,,,199.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.29,,,fee schedule,,,148.29,,,fee schedule,,,148.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,148.29,,,fee schedule,,,,,,,,,,,,,,,148.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PALIPERIDONE 3 MG TAB,2500019900,CDM,637,RC,6516228103,NDC,,,,,,inpatient,facility,3,UN,100.98,100.98,8.08,100.98,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,,,,,,,100.98,,,percent of total billed charges,,,51.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.59,,,percent of total billed charges,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,85.83,,,percent of total billed charges,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,53.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,8.08,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,
PALIPERIDONE 3 MG TAB,2500019900,CDM,637,RC,6516228103,NDC,,,,,,outpatient,facility,3,UN,100.98,100.98,8.08,548.68,,71.6,,,percent of total billed charges,,,24.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,100.98,,,percent of total billed charges,,,63.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,70.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,70.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,36.96,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,100.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,100.98,,,fee schedule,,,100.98,,,percent of total billed charges,,,,,,,,,100.98,,,percent of total billed charges,,,61.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.95,,,percent of total billed charges,,,,,,,,,,,,,,,54.53,,,percent of total billed charges,,,52.51,,,percent of total billed charges,,,55.54,,,percent of total billed charges,,,,,,,,,59.58,,,percent of total billed charges,,,548.68,,,per diem,,,100.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,100.98,,,percent of total billed charges,,,85.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.63,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.12,,,percent of total billed charges,,,81.71,,,percent of total billed charges,,,,,,,,,,,,,,,40.39,,,percent of total billed charges,,,,,,,,,37.36,,,percent of total billed charges,,,37.36,,,percent of total billed charges,,,,,,,,,100.98,,,percent of total billed charges,,,100.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,100.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.08,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,,,,,,,93.93,,,percent of total billed charges,,,,,,,,,,,,,,,93.93,,,percent of total billed charges,,,93.93,,,percent of total billed charges,,,93.93,,,percent of total billed charges,,,75.73,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,,,,,,,70.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,59.5,,,percent of total billed charges,,
PALIPERIDONE 3 MG TAB,2500019900,CDM,637,RC,6516228103,NDC,999,EAPG,,,,outpatient,facility,3,UN,100.98,100.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PALIPERIDONE 156 MG IM,2500019909,CDM,636,RC,J2426,HCPCS,5045856301,NDC,,,,inpatient,facility,1,UN,7366.06,7366.06,589.28,7366.06,,,,,,,,,,,,,,7366.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7366.06,,,percent of total billed charges,,,,,,,,,7366.06,,,percent of total billed charges,,,3761.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6273.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4419.64,,,percent of total billed charges,,,,,,,,,,,,,,,7366.06,,,percent of total billed charges,,,6261.15,,,percent of total billed charges,,,,,,,,,,,,,,,7366.06,,,percent of total billed charges,,,3912.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2946.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7366.06,,,percent of total billed charges,,,,,,,,,,,,,,,589.28,,,percent of total billed charges,,,7366.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7366.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4340.08,,,percent of total billed charges,,
PALIPERIDONE 156 MG IM,2500019909,CDM,636,RC,J2426,HCPCS,5045856301,NDC,,,,outpatient,facility,1,UN,7366.06,7366.06,7.63,7366.06,,5223.27,,,percent of total billed charges,,,,,,,,,7366.06,,,percent of total billed charges,,,19.03,,,fee schedule,,,18,,,fee schedule,,,,,,,,,18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7366.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.63,,,fee schedule,,,7366.06,,,fee schedule,,,7366.06,,,percent of total billed charges,,,,,,,,,7366.06,,,percent of total billed charges,,,4514.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5248.32,,,percent of total billed charges,,,,,,,,,,,,,,,14.32,,,fee schedule,,,14.32,,,fee schedule,,,14.32,,,fee schedule,,,,,,,,,4345.98,,,percent of total billed charges,,,548.68,,,per diem,,,7366.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7366.06,,,percent of total billed charges,,,6261.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3912.11,,,percent of total billed charges,,,7366.06,,,percent of total billed charges,,,7366.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4969.14,,,percent of total billed charges,,,5960.62,,,percent of total billed charges,,,,,,,,,,,,,,,2946.42,,,percent of total billed charges,,,,,,,,,32.63,,,fee schedule,,,23.48,,,fee schedule,,,,,,,,,7366.06,,,percent of total billed charges,,,,,,,,,,,,,,,589.28,,,percent of total billed charges,,,7366.06,,,percent of total billed charges,,,,,,,,,,,,,,,7366.06,,,percent of total billed charges,,,7366.06,,,percent of total billed charges,,,,,,,,,13.94,,,fee schedule,,,,,,,,,,,,,,,12.08,,,fee schedule,,,16.11,,,fee schedule,,,9.06,,,fee schedule,,,15.21,,,fee schedule,,,7366.06,,,percent of total billed charges,,,7366.06,,,percent of total billed charges,,,7366.06,,,percent of total billed charges,,,,,,,,,5164.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3683.03,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4340.08,,,percent of total billed charges,,
PALIPERIDONE 156 MG IM,2500019909,CDM,636,RC,J2426,HCPCS,5045856301,NDC,9255,APC,,outpatient,facility,1,UN,7366.06,7366.06,14.14,2695.98,,,,,,,,15.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,14.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.88,,,fee schedule,,,,,,,,,2695.98,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,14.73,,,fee schedule,,,,,,,,,,,,,,,15.47,,,fee schedule,,,15.47,,,fee schedule,,,,,,,,,14.73,,,fee schedule,,,14.73,,,fee schedule,,,15.47,,,fee schedule,,,,,,,,,,,,,,,22.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,14.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.14,,,fee schedule,,,15.76,,,fee schedule,,,15.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.73,,,fee schedule,,,14.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,15.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,14.73,,,fee schedule,,,,,,,,,18.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,14.73,,,fee schedule,,,14.73,,,fee schedule,,,,,,,,,,,,,,,14.73,,,fee schedule,,,,,,,,,14.73,,,fee schedule,,,15.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.73,,,fee schedule,,,,,,,,,,,,,,,15.32,,,fee schedule,,,14.73,,,fee schedule,,,,,,,,,14.73,,,fee schedule,,,,,,,,,14.73,,,fee schedule,,,15.47,,,fee schedule,,,,,,,,
PALIPERIDONE 156 MG IM,2500019909,CDM,636,RC,J2426,HCPCS,5045856301,NDC,444,EAPG,,outpatient,facility,1,UN,7366.06,7366.06,1304.36,1969.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1969.58,,,fee schedule,,,1304.36,,,fee schedule,,,1750.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMMUNE GLOBULIN IVIG 20 G,2500019923,CDM,636,RC,J1569,HCPCS,944270006,NDC,,,,inpatient,facility,200,ML,10655.7,10655.7,852.46,10655.7,,,,,,,,,,,,,,10655.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10655.7,,,percent of total billed charges,,,,,,,,,10655.7,,,percent of total billed charges,,,5440.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9075.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6393.42,,,percent of total billed charges,,,,,,,,,,,,,,,10655.7,,,percent of total billed charges,,,9057.35,,,percent of total billed charges,,,,,,,,,,,,,,,10655.7,,,percent of total billed charges,,,5659.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4262.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10655.7,,,percent of total billed charges,,,,,,,,,,,,,,,852.46,,,percent of total billed charges,,,10655.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10655.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6278.34,,,percent of total billed charges,,
IMMUNE GLOBULIN IVIG 20 G,2500019923,CDM,636,RC,J1569,HCPCS,944270006,NDC,,,,outpatient,facility,200,ML,10655.7,10655.7,30.87,10655.7,,7555.96,,,percent of total billed charges,,,,,,,,,10655.7,,,percent of total billed charges,,,58.5,,,fee schedule,,,55.35,,,fee schedule,,,,,,,,,55.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,10655.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,43.38,,,fee schedule,,,10655.7,,,fee schedule,,,10655.7,,,percent of total billed charges,,,,,,,,,10655.7,,,percent of total billed charges,,,6530.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7592.19,,,percent of total billed charges,,,,,,,,,,,,,,,44.15,,,fee schedule,,,44.15,,,fee schedule,,,44.15,,,fee schedule,,,,,,,,,6286.86,,,percent of total billed charges,,,548.68,,,per diem,,,10655.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10655.7,,,percent of total billed charges,,,9057.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5659.24,,,percent of total billed charges,,,10655.7,,,percent of total billed charges,,,10655.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7188.34,,,percent of total billed charges,,,8622.59,,,percent of total billed charges,,,,,,,,,,,,,,,4262.28,,,percent of total billed charges,,,,,,,,,111.13,,,fee schedule,,,79.97,,,fee schedule,,,,,,,,,10655.7,,,percent of total billed charges,,,,,,,,,,,,,,,852.46,,,percent of total billed charges,,,10655.7,,,percent of total billed charges,,,,,,,,,,,,,,,10655.7,,,percent of total billed charges,,,10655.7,,,percent of total billed charges,,,,,,,,,47.49,,,fee schedule,,,,,,,,,,,,,,,41.16,,,fee schedule,,,54.88,,,fee schedule,,,30.87,,,fee schedule,,,46.77,,,fee schedule,,,10655.7,,,percent of total billed charges,,,10655.7,,,percent of total billed charges,,,10655.7,,,percent of total billed charges,,,,,,,,,7470.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5327.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6278.34,,,percent of total billed charges,,
IMMUNE GLOBULIN IVIG 20 G,2500019923,CDM,636,RC,J1569,HCPCS,944270006,NDC,944,APC,,outpatient,facility,200,ML,10655.7,10655.7,44.6,3899.99,,,,,,,,47.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,46.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.92,,,fee schedule,,,,,,,,,3899.99,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,46.46,,,fee schedule,,,,,,,,,,,,,,,48.78,,,fee schedule,,,48.78,,,fee schedule,,,,,,,,,46.46,,,fee schedule,,,46.46,,,fee schedule,,,48.78,,,fee schedule,,,,,,,,,,,,,,,69.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.6,,,fee schedule,,,49.71,,,fee schedule,,,48.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.46,,,fee schedule,,,46.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,48.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,46.46,,,fee schedule,,,,,,,,,58.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,58.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,46.46,,,fee schedule,,,46.46,,,fee schedule,,,,,,,,,,,,,,,46.46,,,fee schedule,,,,,,,,,46.46,,,fee schedule,,,47.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.46,,,fee schedule,,,,,,,,,,,,,,,48.32,,,fee schedule,,,46.46,,,fee schedule,,,,,,,,,46.46,,,fee schedule,,,,,,,,,46.46,,,fee schedule,,,48.78,,,fee schedule,,,,,,,,
IMMUNE GLOBULIN IVIG 20 G,2500019923,CDM,636,RC,J1569,HCPCS,944270006,NDC,461,EAPG,,outpatient,facility,200,ML,10655.7,10655.7,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMMUNE GLOB IV 5 GM/ GAMUNEX,2500019950,CDM,636,RC,J1561,HCPCS,1353380020,NDC,,,,inpatient,facility,50,UN,2338.88,2338.88,187.11,2338.88,,,,,,,,,,,,,,2338.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2338.88,,,percent of total billed charges,,,,,,,,,2338.88,,,percent of total billed charges,,,1194.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1992.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1403.33,,,percent of total billed charges,,,,,,,,,,,,,,,2338.88,,,percent of total billed charges,,,1988.05,,,percent of total billed charges,,,,,,,,,,,,,,,2338.88,,,percent of total billed charges,,,1242.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,935.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2338.88,,,percent of total billed charges,,,,,,,,,,,,,,,187.11,,,percent of total billed charges,,,2338.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2338.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1378.07,,,percent of total billed charges,,
IMMUNE GLOB IV 5 GM/ GAMUNEX,2500019950,CDM,636,RC,J1561,HCPCS,1353380020,NDC,,,,outpatient,facility,50,UN,2338.88,2338.88,30.49,2338.88,,1658.5,,,percent of total billed charges,,,,,,,,,2338.88,,,percent of total billed charges,,,64.35,,,fee schedule,,,60.88,,,fee schedule,,,,,,,,,60.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2338.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,42.96,,,fee schedule,,,2338.88,,,fee schedule,,,2338.88,,,percent of total billed charges,,,,,,,,,2338.88,,,percent of total billed charges,,,1433.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.45,,,percent of total billed charges,,,,,,,,,,,,,,,49.79,,,fee schedule,,,49.79,,,fee schedule,,,49.79,,,fee schedule,,,,,,,,,1379.94,,,percent of total billed charges,,,548.68,,,per diem,,,2338.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2338.88,,,percent of total billed charges,,,1988.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1242.18,,,percent of total billed charges,,,2338.88,,,percent of total billed charges,,,2338.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1577.81,,,percent of total billed charges,,,1892.62,,,percent of total billed charges,,,,,,,,,,,,,,,935.55,,,percent of total billed charges,,,,,,,,,109.75,,,fee schedule,,,78.98,,,fee schedule,,,,,,,,,2338.88,,,percent of total billed charges,,,,,,,,,,,,,,,187.11,,,percent of total billed charges,,,2338.88,,,percent of total billed charges,,,,,,,,,,,,,,,2338.88,,,percent of total billed charges,,,2338.88,,,percent of total billed charges,,,,,,,,,46.9,,,fee schedule,,,,,,,,,,,,,,,40.65,,,fee schedule,,,54.2,,,fee schedule,,,30.49,,,fee schedule,,,51.45,,,fee schedule,,,2338.88,,,percent of total billed charges,,,2338.88,,,percent of total billed charges,,,2338.88,,,percent of total billed charges,,,,,,,,,1639.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1169.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1378.07,,,percent of total billed charges,,
IMMUNE GLOB IV 5 GM/ GAMUNEX,2500019950,CDM,636,RC,J1561,HCPCS,1353380020,NDC,948,APC,,outpatient,facility,50,UN,2338.88,2338.88,47.05,856.03,,,,,,,,50.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,fee schedule,,,,,,,,,856.03,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,51.46,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,49.01,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,,,,,,,,73.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.05,,,fee schedule,,,52.44,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,49.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,50.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,61.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,61.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,49.01,,,fee schedule,,,49.01,,,fee schedule,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,50.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,50.97,,,fee schedule,,,49.01,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,
IMMUNE GLOB IV 5 GM/ GAMUNEX,2500019950,CDM,636,RC,J1561,HCPCS,1353380020,NDC,460,EAPG,,outpatient,facility,50,UN,2338.88,2338.88,1604.23,2422.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2422.39,,,fee schedule,,,1604.23,,,fee schedule,,,2153.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMMUNE GLOB IV 10 GM/GAMUNEX,2500019960,CDM,636,RC,J1561,HCPCS,1353380071,NDC,,,,inpatient,facility,100,ML,4677.75,4677.75,374.22,4677.75,,,,,,,,,,,,,,4677.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4677.75,,,percent of total billed charges,,,,,,,,,4677.75,,,percent of total billed charges,,,2388.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3984.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2806.65,,,percent of total billed charges,,,,,,,,,,,,,,,4677.75,,,percent of total billed charges,,,3976.09,,,percent of total billed charges,,,,,,,,,,,,,,,4677.75,,,percent of total billed charges,,,2484.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1871.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4677.75,,,percent of total billed charges,,,,,,,,,,,,,,,374.22,,,percent of total billed charges,,,4677.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4677.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2756.13,,,percent of total billed charges,,
IMMUNE GLOB IV 10 GM/GAMUNEX,2500019960,CDM,636,RC,J1561,HCPCS,1353380071,NDC,,,,outpatient,facility,100,ML,4677.75,4677.75,30.49,4677.75,,3316.99,,,percent of total billed charges,,,,,,,,,4677.75,,,percent of total billed charges,,,64.35,,,fee schedule,,,60.88,,,fee schedule,,,,,,,,,60.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4677.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,42.96,,,fee schedule,,,4677.75,,,fee schedule,,,4677.75,,,percent of total billed charges,,,,,,,,,4677.75,,,percent of total billed charges,,,2866.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3332.9,,,percent of total billed charges,,,,,,,,,,,,,,,49.79,,,fee schedule,,,49.79,,,fee schedule,,,49.79,,,fee schedule,,,,,,,,,2759.87,,,percent of total billed charges,,,548.68,,,per diem,,,4677.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4677.75,,,percent of total billed charges,,,3976.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2484.35,,,percent of total billed charges,,,4677.75,,,percent of total billed charges,,,4677.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3155.61,,,percent of total billed charges,,,3785.24,,,percent of total billed charges,,,,,,,,,,,,,,,1871.1,,,percent of total billed charges,,,,,,,,,109.75,,,fee schedule,,,78.98,,,fee schedule,,,,,,,,,4677.75,,,percent of total billed charges,,,,,,,,,,,,,,,374.22,,,percent of total billed charges,,,4677.75,,,percent of total billed charges,,,,,,,,,,,,,,,4677.75,,,percent of total billed charges,,,4677.75,,,percent of total billed charges,,,,,,,,,46.9,,,fee schedule,,,,,,,,,,,,,,,40.65,,,fee schedule,,,54.2,,,fee schedule,,,30.49,,,fee schedule,,,51.45,,,fee schedule,,,4677.75,,,percent of total billed charges,,,4677.75,,,percent of total billed charges,,,4677.75,,,percent of total billed charges,,,,,,,,,3279.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2338.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2756.13,,,percent of total billed charges,,
IMMUNE GLOB IV 10 GM/GAMUNEX,2500019960,CDM,636,RC,J1561,HCPCS,1353380071,NDC,948,APC,,outpatient,facility,100,ML,4677.75,4677.75,47.05,1712.06,,,,,,,,50.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,fee schedule,,,,,,,,,1712.06,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,51.46,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,49.01,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,,,,,,,,73.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.05,,,fee schedule,,,52.44,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,49.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,50.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,61.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,61.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,49.01,,,fee schedule,,,49.01,,,fee schedule,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,50.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,50.97,,,fee schedule,,,49.01,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,
IMMUNE GLOB IV 10 GM/GAMUNEX,2500019960,CDM,636,RC,J1561,HCPCS,1353380071,NDC,460,EAPG,,outpatient,facility,100,ML,4677.75,4677.75,1604.23,2422.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2422.39,,,fee schedule,,,1604.23,,,fee schedule,,,2153.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMMUNE GLOB IV 20 GM/GAMUNEX,2500019970,CDM,636,RC,J1561,HCPCS,1353380024,NDC,,,,inpatient,facility,200,ML,9355.5,9355.5,748.44,9355.5,,,,,,,,,,,,,,9355.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9355.5,,,percent of total billed charges,,,,,,,,,9355.5,,,percent of total billed charges,,,4776.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7968.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5613.3,,,percent of total billed charges,,,,,,,,,,,,,,,9355.5,,,percent of total billed charges,,,7952.18,,,percent of total billed charges,,,,,,,,,,,,,,,9355.5,,,percent of total billed charges,,,4968.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3742.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9355.5,,,percent of total billed charges,,,,,,,,,,,,,,,748.44,,,percent of total billed charges,,,9355.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9355.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5512.26,,,percent of total billed charges,,
IMMUNE GLOB IV 20 GM/GAMUNEX,2500019970,CDM,636,RC,J1561,HCPCS,1353380024,NDC,,,,outpatient,facility,200,ML,9355.5,9355.5,30.49,9355.5,,6633.99,,,percent of total billed charges,,,,,,,,,9355.5,,,percent of total billed charges,,,64.35,,,fee schedule,,,60.88,,,fee schedule,,,,,,,,,60.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,9355.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,42.96,,,fee schedule,,,9355.5,,,fee schedule,,,9355.5,,,percent of total billed charges,,,,,,,,,9355.5,,,percent of total billed charges,,,5733.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6665.79,,,percent of total billed charges,,,,,,,,,,,,,,,49.79,,,fee schedule,,,49.79,,,fee schedule,,,49.79,,,fee schedule,,,,,,,,,5519.74,,,percent of total billed charges,,,548.68,,,per diem,,,9355.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9355.5,,,percent of total billed charges,,,7952.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4968.71,,,percent of total billed charges,,,9355.5,,,percent of total billed charges,,,9355.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6311.22,,,percent of total billed charges,,,7570.47,,,percent of total billed charges,,,,,,,,,,,,,,,3742.2,,,percent of total billed charges,,,,,,,,,109.75,,,fee schedule,,,78.98,,,fee schedule,,,,,,,,,9355.5,,,percent of total billed charges,,,,,,,,,,,,,,,748.44,,,percent of total billed charges,,,9355.5,,,percent of total billed charges,,,,,,,,,,,,,,,9355.5,,,percent of total billed charges,,,9355.5,,,percent of total billed charges,,,,,,,,,46.9,,,fee schedule,,,,,,,,,,,,,,,40.65,,,fee schedule,,,54.2,,,fee schedule,,,30.49,,,fee schedule,,,51.45,,,fee schedule,,,9355.5,,,percent of total billed charges,,,9355.5,,,percent of total billed charges,,,9355.5,,,percent of total billed charges,,,,,,,,,6559.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4677.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5512.26,,,percent of total billed charges,,
IMMUNE GLOB IV 20 GM/GAMUNEX,2500019970,CDM,636,RC,J1561,HCPCS,1353380024,NDC,948,APC,,outpatient,facility,200,ML,9355.5,9355.5,47.05,3424.11,,,,,,,,50.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,fee schedule,,,,,,,,,3424.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,51.46,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,49.01,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,,,,,,,,73.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.05,,,fee schedule,,,52.44,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,49.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,50.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,61.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,61.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,49.01,,,fee schedule,,,49.01,,,fee schedule,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,50.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,50.97,,,fee schedule,,,49.01,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,
IMMUNE GLOB IV 20 GM/GAMUNEX,2500019970,CDM,636,RC,J1561,HCPCS,1353380024,NDC,460,EAPG,,outpatient,facility,200,ML,9355.5,9355.5,1604.23,2422.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2422.39,,,fee schedule,,,1604.23,,,fee schedule,,,2153.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RHO(D) IMMUNE-RHOPHYLAC 1500IU,2500019980,CDM,636,RC,J2791,HCPCS,4420630001,NDC,,,,inpatient,facility,2,UN,545.13,545.13,43.61,545.13,,,,,,,,,,,,,,545.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,545.13,,,percent of total billed charges,,,,,,,,,545.13,,,percent of total billed charges,,,278.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,327.08,,,percent of total billed charges,,,,,,,,,,,,,,,545.13,,,percent of total billed charges,,,463.36,,,percent of total billed charges,,,,,,,,,,,,,,,545.13,,,percent of total billed charges,,,289.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,545.13,,,percent of total billed charges,,,,,,,,,,,,,,,43.61,,,percent of total billed charges,,,545.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,545.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,321.19,,,percent of total billed charges,,
RHO(D) IMMUNE-RHOPHYLAC 1500IU,2500019980,CDM,636,RC,J2791,HCPCS,4420630001,NDC,,,,outpatient,facility,2,UN,545.13,545.13,4.94,548.68,,386.55,,,percent of total billed charges,,,133.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,545.13,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,545.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,199.52,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,545.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,545.13,,,fee schedule,,,545.13,,,percent of total billed charges,,,,,,,,,545.13,,,percent of total billed charges,,,334.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,321.63,,,percent of total billed charges,,,548.68,,,per diem,,,545.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,545.13,,,percent of total billed charges,,,463.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,289.52,,,percent of total billed charges,,,545.13,,,percent of total billed charges,,,545.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,367.74,,,percent of total billed charges,,,441.12,,,percent of total billed charges,,,,,,,,,,,,,,,218.05,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,545.13,,,percent of total billed charges,,,545.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,545.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.61,,,percent of total billed charges,,,545.13,,,percent of total billed charges,,,,,,,,,,,,,,,545.13,,,percent of total billed charges,,,545.13,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,4.94,,,fee schedule,,,545.13,,,percent of total billed charges,,,545.13,,,percent of total billed charges,,,545.13,,,percent of total billed charges,,,,,,,,,382.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,321.19,,,percent of total billed charges,,
RHO(D) IMMUNE-RHOPHYLAC 1500IU,2500019980,CDM,636,RC,J2791,HCPCS,4420630001,NDC,436,EAPG,,outpatient,facility,2,UN,545.13,545.13,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ZOLEDRONIC ACID 5 MG/RECLAST,2500020030,CDM,636,RC,J3489,HCPCS,5511168852,NDC,,,,inpatient,facility,100,ML,3314.59,3314.59,265.17,3314.59,,,,,,,,,,,,,,3314.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3314.59,,,percent of total billed charges,,,,,,,,,3314.59,,,percent of total billed charges,,,1692.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2823.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1988.75,,,percent of total billed charges,,,,,,,,,,,,,,,3314.59,,,percent of total billed charges,,,2817.4,,,percent of total billed charges,,,,,,,,,,,,,,,3314.59,,,percent of total billed charges,,,1760.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1325.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3314.59,,,percent of total billed charges,,,,,,,,,,,,,,,265.17,,,percent of total billed charges,,,3314.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3314.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1952.96,,,percent of total billed charges,,
ZOLEDRONIC ACID 5 MG/RECLAST,2500020030,CDM,636,RC,J3489,HCPCS,5511168852,NDC,,,,outpatient,facility,100,ML,3314.59,3314.59,5.94,3314.59,,2350.38,,,percent of total billed charges,,,808.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3314.59,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,3314.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1213.14,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,120.18,,,fee schedule,,,3314.59,,,fee schedule,,,3314.59,,,percent of total billed charges,,,,,,,,,3314.59,,,percent of total billed charges,,,2031.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2361.65,,,percent of total billed charges,,,,,,,,,,,,,,,7.21,,,fee schedule,,,7.21,,,fee schedule,,,7.21,,,fee schedule,,,,,,,,,1955.61,,,percent of total billed charges,,,548.68,,,per diem,,,3314.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3314.59,,,percent of total billed charges,,,2817.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1760.38,,,percent of total billed charges,,,3314.59,,,percent of total billed charges,,,3314.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2236.02,,,percent of total billed charges,,,2682.17,,,percent of total billed charges,,,,,,,,,,,,,,,1325.84,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3314.59,,,percent of total billed charges,,,3314.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3314.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,265.17,,,percent of total billed charges,,,3314.59,,,percent of total billed charges,,,,,,,,,,,,,,,3314.59,,,percent of total billed charges,,,3314.59,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,5.94,,,fee schedule,,,3314.59,,,percent of total billed charges,,,3314.59,,,percent of total billed charges,,,3314.59,,,percent of total billed charges,,,,,,,,,2323.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1657.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1952.96,,,percent of total billed charges,,
ZOLEDRONIC ACID 5 MG/RECLAST,2500020030,CDM,636,RC,J3489,HCPCS,5511168852,NDC,435,EAPG,,outpatient,facility,100,ML,3314.59,3314.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.9  FLUSH 10ML,2500020101,CDM,250,RC,6332318610,NDC,,,,,,inpatient,facility,10,ML,3.37,3.37,0.27,3.37,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,3.37,,,percent of total billed charges,,,1.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.99,,,percent of total billed charges,,
SOD CHLORIDE 0.9  FLUSH 10ML,2500020101,CDM,250,RC,6332318610,NDC,,,,,,outpatient,facility,10,ML,3.37,3.37,0.27,548.68,,2.39,,,percent of total billed charges,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.37,,,percent of total billed charges,,,2.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.37,,,fee schedule,,,3.37,,,percent of total billed charges,,,,,,,,,3.37,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,1.99,,,percent of total billed charges,,,548.68,,,per diem,,,3.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.37,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.79,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.27,,,percent of total billed charges,,,2.73,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,,,,,,,3.37,,,percent of total billed charges,,,3.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.27,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,1.35,,,percent of total billed charges,,,2.53,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,3.37,,,percent of total billed charges,,,,,,,,,2.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.99,,,percent of total billed charges,,
SOD CHLORIDE 0.9  FLUSH 10ML,2500020101,CDM,250,RC,6332318610,NDC,999,EAPG,,,,outpatient,facility,10,ML,3.37,3.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.9  FLUSH 3 ML,2500020102,CDM,250,RC,6380710035,NDC,,,,,,inpatient,facility,3,ML,1.38,1.38,0.11,1.38,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,1.38,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,,percent of total billed charges,,
SOD CHLORIDE 0.9  FLUSH 3 ML,2500020102,CDM,250,RC,6380710035,NDC,,,,,,outpatient,facility,3,ML,1.38,1.38,0.11,548.68,,0.98,,,percent of total billed charges,,,0.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.38,,,percent of total billed charges,,,0.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.51,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.38,,,fee schedule,,,1.38,,,percent of total billed charges,,,,,,,,,1.38,,,percent of total billed charges,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,0.81,,,percent of total billed charges,,,548.68,,,per diem,,,1.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.38,,,percent of total billed charges,,,1.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,,,,,,,1.38,,,percent of total billed charges,,,1.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,0.55,,,percent of total billed charges,,,1.03,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,0.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.81,,,percent of total billed charges,,
SOD CHLORIDE 0.9  FLUSH 3 ML,2500020102,CDM,250,RC,6380710035,NDC,999,EAPG,,,,outpatient,facility,3,ML,1.38,1.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD CHLORIDE 0.9  FLUSH 5 ML,2500020103,CDM,250,RC,6425311125,NDC,,,,,,inpatient,facility,5,ML,10.53,10.53,0.84,10.53,,,,,,,,,,,,,,10.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.53,,,percent of total billed charges,,,,,,,,,10.53,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.32,,,percent of total billed charges,,,,,,,,,,,,,,,10.53,,,percent of total billed charges,,,8.95,,,percent of total billed charges,,,,,,,,,,,,,,,10.53,,,percent of total billed charges,,,5.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,10.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.2,,,percent of total billed charges,,
SOD CHLORIDE 0.9  FLUSH 5 ML,2500020103,CDM,250,RC,6425311125,NDC,,,,,,outpatient,facility,5,ML,10.53,10.53,0.84,548.68,,7.47,,,percent of total billed charges,,,2.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.53,,,percent of total billed charges,,,6.6,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.4,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.85,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.53,,,fee schedule,,,10.53,,,percent of total billed charges,,,,,,,,,10.53,,,percent of total billed charges,,,6.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,6.21,,,percent of total billed charges,,,548.68,,,per diem,,,10.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.53,,,percent of total billed charges,,,8.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.59,,,percent of total billed charges,,,10.53,,,percent of total billed charges,,,10.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.1,,,percent of total billed charges,,,8.52,,,percent of total billed charges,,,,,,,,,,,,,,,4.21,,,percent of total billed charges,,,,,,,,,4.21,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,,,,,,,10.53,,,percent of total billed charges,,,10.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.84,,,percent of total billed charges,,,10.53,,,percent of total billed charges,,,,,,,,,,,,,,,10.53,,,percent of total billed charges,,,10.53,,,percent of total billed charges,,,,,,,,,4.21,,,percent of total billed charges,,,,,,,,,,,,,,,4.21,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,7.9,,,percent of total billed charges,,,10.53,,,percent of total billed charges,,,10.53,,,percent of total billed charges,,,10.53,,,percent of total billed charges,,,,,,,,,7.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.26,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.2,,,percent of total billed charges,,
SOD CHLORIDE 0.9  FLUSH 5 ML,2500020103,CDM,250,RC,6425311125,NDC,999,EAPG,,,,outpatient,facility,5,ML,10.53,10.53,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RANOLAZINE 500 MG TAB ER,2500020135,CDM,637,RC,7075670360,NDC,,,,,,inpatient,facility,500,UN,21.18,21.18,1.69,21.18,,,,,,,,,,,,,,21.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,percent of total billed charges,,,,,,,,,21.18,,,percent of total billed charges,,,10.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.71,,,percent of total billed charges,,,,,,,,,,,,,,,21.18,,,percent of total billed charges,,,18,,,percent of total billed charges,,,,,,,,,,,,,,,21.18,,,percent of total billed charges,,,11.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,percent of total billed charges,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,21.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.48,,,percent of total billed charges,,
RANOLAZINE 500 MG TAB ER,2500020135,CDM,637,RC,7075670360,NDC,,,,,,outpatient,facility,500,UN,21.18,21.18,1.69,548.68,,15.02,,,percent of total billed charges,,,5.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,21.18,,,percent of total billed charges,,,13.27,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,14.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,14.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.75,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,21.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,21.18,,,fee schedule,,,21.18,,,percent of total billed charges,,,,,,,,,21.18,,,percent of total billed charges,,,12.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.09,,,percent of total billed charges,,,,,,,,,,,,,,,11.44,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,11.65,,,percent of total billed charges,,,,,,,,,12.5,,,percent of total billed charges,,,548.68,,,per diem,,,21.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,21.18,,,percent of total billed charges,,,18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.25,,,percent of total billed charges,,,21.18,,,percent of total billed charges,,,21.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.29,,,percent of total billed charges,,,17.14,,,percent of total billed charges,,,,,,,,,,,,,,,8.47,,,percent of total billed charges,,,,,,,,,7.84,,,percent of total billed charges,,,7.84,,,percent of total billed charges,,,,,,,,,21.18,,,percent of total billed charges,,,21.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.69,,,percent of total billed charges,,,21.18,,,percent of total billed charges,,,,,,,,,,,,,,,21.18,,,percent of total billed charges,,,21.18,,,percent of total billed charges,,,,,,,,,19.7,,,percent of total billed charges,,,,,,,,,,,,,,,19.7,,,percent of total billed charges,,,19.7,,,percent of total billed charges,,,19.7,,,percent of total billed charges,,,15.88,,,percent of total billed charges,,,21.18,,,percent of total billed charges,,,21.18,,,percent of total billed charges,,,21.18,,,percent of total billed charges,,,,,,,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,12.48,,,percent of total billed charges,,
RANOLAZINE 500 MG TAB ER,2500020135,CDM,637,RC,7075670360,NDC,999,EAPG,,,,outpatient,facility,500,UN,21.18,21.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DESVENLAFAXINE 50 MG,2500020249,CDM,637,RC,6330419130,NDC,,,,,,inpatient,facility,50,UN,15.31,15.31,1.22,15.31,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,,,,,,,15.31,,,percent of total billed charges,,,7.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.19,,,percent of total billed charges,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,13.01,,,percent of total billed charges,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,8.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.02,,,percent of total billed charges,,
DESVENLAFAXINE 50 MG,2500020249,CDM,637,RC,6330419130,NDC,,,,,,outpatient,facility,50,UN,15.31,15.31,1.22,548.68,,10.86,,,percent of total billed charges,,,3.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,15.31,,,percent of total billed charges,,,9.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.6,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,15.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,15.31,,,fee schedule,,,15.31,,,percent of total billed charges,,,,,,,,,15.31,,,percent of total billed charges,,,9.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.91,,,percent of total billed charges,,,,,,,,,,,,,,,8.27,,,percent of total billed charges,,,7.96,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,9.03,,,percent of total billed charges,,,548.68,,,per diem,,,15.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,15.31,,,percent of total billed charges,,,13.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.13,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.33,,,percent of total billed charges,,,12.39,,,percent of total billed charges,,,,,,,,,,,,,,,6.12,,,percent of total billed charges,,,,,,,,,5.66,,,percent of total billed charges,,,5.66,,,percent of total billed charges,,,,,,,,,15.31,,,percent of total billed charges,,,15.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.22,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,15.31,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,,,,,,,14.24,,,percent of total billed charges,,,,,,,,,,,,,,,14.24,,,percent of total billed charges,,,14.24,,,percent of total billed charges,,,14.24,,,percent of total billed charges,,,11.48,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,15.31,,,percent of total billed charges,,,,,,,,,10.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.02,,,percent of total billed charges,,
DESVENLAFAXINE 50 MG,2500020249,CDM,637,RC,6330419130,NDC,999,EAPG,,,,outpatient,facility,50,UN,15.31,15.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RASAGILINE 1 MG TAB,2500020252,CDM,637,RC,6787726030,NDC,,,,,,inpatient,facility,1,UN,82.43,82.43,6.59,82.43,,,,,,,,,,,,,,82.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.43,,,percent of total billed charges,,,,,,,,,82.43,,,percent of total billed charges,,,42.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.46,,,percent of total billed charges,,,,,,,,,,,,,,,82.43,,,percent of total billed charges,,,70.07,,,percent of total billed charges,,,,,,,,,,,,,,,82.43,,,percent of total billed charges,,,43.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,82.43,,,percent of total billed charges,,,,,,,,,,,,,,,6.59,,,percent of total billed charges,,,82.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.57,,,percent of total billed charges,,
RASAGILINE 1 MG TAB,2500020252,CDM,637,RC,6787726030,NDC,,,,,,outpatient,facility,1,UN,82.43,82.43,6.59,548.68,,58.45,,,percent of total billed charges,,,20.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,82.43,,,percent of total billed charges,,,51.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,57.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,57.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,82.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,30.17,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,82.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,82.43,,,fee schedule,,,82.43,,,percent of total billed charges,,,,,,,,,82.43,,,percent of total billed charges,,,50.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.73,,,percent of total billed charges,,,,,,,,,,,,,,,44.51,,,percent of total billed charges,,,42.86,,,percent of total billed charges,,,45.34,,,percent of total billed charges,,,,,,,,,48.63,,,percent of total billed charges,,,548.68,,,per diem,,,82.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,82.43,,,percent of total billed charges,,,70.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.78,,,percent of total billed charges,,,82.43,,,percent of total billed charges,,,82.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.61,,,percent of total billed charges,,,66.7,,,percent of total billed charges,,,,,,,,,,,,,,,32.97,,,percent of total billed charges,,,,,,,,,30.5,,,percent of total billed charges,,,30.5,,,percent of total billed charges,,,,,,,,,82.43,,,percent of total billed charges,,,82.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,82.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.59,,,percent of total billed charges,,,82.43,,,percent of total billed charges,,,,,,,,,,,,,,,82.43,,,percent of total billed charges,,,82.43,,,percent of total billed charges,,,,,,,,,76.68,,,percent of total billed charges,,,,,,,,,,,,,,,76.68,,,percent of total billed charges,,,76.68,,,percent of total billed charges,,,76.68,,,percent of total billed charges,,,61.82,,,percent of total billed charges,,,82.43,,,percent of total billed charges,,,82.43,,,percent of total billed charges,,,82.43,,,percent of total billed charges,,,,,,,,,57.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,48.57,,,percent of total billed charges,,
RASAGILINE 1 MG TAB,2500020252,CDM,637,RC,6787726030,NDC,999,EAPG,,,,outpatient,facility,1,UN,82.43,82.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALVIMOPAN 12 MG,2500020256,CDM,637,RC,6791902010,NDC,,,,,,inpatient,facility,12,UN,600.07,600.07,48.01,600.07,,,,,,,,,,,,,,600.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.07,,,percent of total billed charges,,,,,,,,,600.07,,,percent of total billed charges,,,306.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.04,,,percent of total billed charges,,,,,,,,,,,,,,,600.07,,,percent of total billed charges,,,510.06,,,percent of total billed charges,,,,,,,,,,,,,,,600.07,,,percent of total billed charges,,,318.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,600.07,,,percent of total billed charges,,,,,,,,,,,,,,,48.01,,,percent of total billed charges,,,600.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,600.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,353.56,,,percent of total billed charges,,
ALVIMOPAN 12 MG,2500020256,CDM,637,RC,6791902010,NDC,,,,,,outpatient,facility,12,UN,600.07,600.07,48.01,600.07,,425.51,,,percent of total billed charges,,,146.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,600.07,,,percent of total billed charges,,,376.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,421.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,421.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,600.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,219.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,600.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,600.07,,,fee schedule,,,600.07,,,percent of total billed charges,,,,,,,,,600.07,,,percent of total billed charges,,,367.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,427.55,,,percent of total billed charges,,,,,,,,,,,,,,,324.04,,,percent of total billed charges,,,312.04,,,percent of total billed charges,,,330.04,,,percent of total billed charges,,,,,,,,,354.04,,,percent of total billed charges,,,548.68,,,per diem,,,600.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,600.07,,,percent of total billed charges,,,510.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,318.7,,,percent of total billed charges,,,600.07,,,percent of total billed charges,,,600.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.81,,,percent of total billed charges,,,485.58,,,percent of total billed charges,,,,,,,,,,,,,,,240.03,,,percent of total billed charges,,,,,,,,,222.03,,,percent of total billed charges,,,222.03,,,percent of total billed charges,,,,,,,,,600.07,,,percent of total billed charges,,,600.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,600.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,48.01,,,percent of total billed charges,,,600.07,,,percent of total billed charges,,,,,,,,,,,,,,,600.07,,,percent of total billed charges,,,600.07,,,percent of total billed charges,,,,,,,,,558.19,,,percent of total billed charges,,,,,,,,,,,,,,,558.19,,,percent of total billed charges,,,558.19,,,percent of total billed charges,,,558.19,,,percent of total billed charges,,,450.05,,,percent of total billed charges,,,600.07,,,percent of total billed charges,,,600.07,,,percent of total billed charges,,,600.07,,,percent of total billed charges,,,,,,,,,420.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,300.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,353.56,,,percent of total billed charges,,
ALVIMOPAN 12 MG,2500020256,CDM,637,RC,6791902010,NDC,999,EAPG,,,,outpatient,facility,12,UN,600.07,600.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MICAFUNGIN 100 MG INJ,2500020265,CDM,636,RC,J2248,HCPCS,469321110,NDC,,,,inpatient,facility,100,UN,617.1,617.1,49.37,617.1,,,,,,,,,,,,,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,617.1,,,percent of total billed charges,,,,,,,,,617.1,,,percent of total billed charges,,,315.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.26,,,percent of total billed charges,,,,,,,,,,,,,,,617.1,,,percent of total billed charges,,,524.54,,,percent of total billed charges,,,,,,,,,,,,,,,617.1,,,percent of total billed charges,,,327.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,246.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,,49.37,,,percent of total billed charges,,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.6,,,percent of total billed charges,,
MICAFUNGIN 100 MG INJ,2500020265,CDM,636,RC,J2248,HCPCS,469321110,NDC,,,,outpatient,facility,100,UN,617.1,617.1,0.44,617.1,,437.59,,,percent of total billed charges,,,150.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,617.1,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,225.86,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.17,,,fee schedule,,,617.1,,,fee schedule,,,617.1,,,percent of total billed charges,,,,,,,,,617.1,,,percent of total billed charges,,,378.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,439.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,364.09,,,percent of total billed charges,,,548.68,,,per diem,,,617.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,617.1,,,percent of total billed charges,,,524.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,327.74,,,percent of total billed charges,,,617.1,,,percent of total billed charges,,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,416.3,,,percent of total billed charges,,,499.36,,,percent of total billed charges,,,,,,,,,,,,,,,246.84,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,617.1,,,percent of total billed charges,,,617.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,617.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,49.37,,,percent of total billed charges,,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,,617.1,,,percent of total billed charges,,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.44,,,fee schedule,,,617.1,,,percent of total billed charges,,,617.1,,,percent of total billed charges,,,617.1,,,percent of total billed charges,,,,,,,,,432.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,363.6,,,percent of total billed charges,,
MICAFUNGIN 100 MG INJ,2500020265,CDM,636,RC,J2248,HCPCS,469321110,NDC,435,EAPG,,outpatient,facility,100,UN,617.1,617.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DRONEDARONE,2500020268,CDM,637,RC,24414260,NDC,,,,,,inpatient,facility,400,UN,41.81,41.81,3.34,41.81,,,,,,,,,,,,,,41.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.81,,,percent of total billed charges,,,,,,,,,41.81,,,percent of total billed charges,,,21.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.09,,,percent of total billed charges,,,,,,,,,,,,,,,41.81,,,percent of total billed charges,,,35.54,,,percent of total billed charges,,,,,,,,,,,,,,,41.81,,,percent of total billed charges,,,22.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,41.81,,,percent of total billed charges,,,,,,,,,,,,,,,3.34,,,percent of total billed charges,,,41.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.63,,,percent of total billed charges,,
DRONEDARONE,2500020268,CDM,637,RC,24414260,NDC,,,,,,outpatient,facility,400,UN,41.81,41.81,3.34,548.68,,29.65,,,percent of total billed charges,,,10.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,41.81,,,percent of total billed charges,,,26.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,29.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,29.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,41.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,15.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,41.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,41.81,,,fee schedule,,,41.81,,,percent of total billed charges,,,,,,,,,41.81,,,percent of total billed charges,,,25.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.79,,,percent of total billed charges,,,,,,,,,,,,,,,22.58,,,percent of total billed charges,,,21.74,,,percent of total billed charges,,,23,,,percent of total billed charges,,,,,,,,,24.67,,,percent of total billed charges,,,548.68,,,per diem,,,41.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,41.81,,,percent of total billed charges,,,35.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.21,,,percent of total billed charges,,,41.81,,,percent of total billed charges,,,41.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.21,,,percent of total billed charges,,,33.83,,,percent of total billed charges,,,,,,,,,,,,,,,16.72,,,percent of total billed charges,,,,,,,,,15.47,,,percent of total billed charges,,,15.47,,,percent of total billed charges,,,,,,,,,41.81,,,percent of total billed charges,,,41.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,41.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.34,,,percent of total billed charges,,,41.81,,,percent of total billed charges,,,,,,,,,,,,,,,41.81,,,percent of total billed charges,,,41.81,,,percent of total billed charges,,,,,,,,,38.89,,,percent of total billed charges,,,,,,,,,,,,,,,38.89,,,percent of total billed charges,,,38.89,,,percent of total billed charges,,,38.89,,,percent of total billed charges,,,31.36,,,percent of total billed charges,,,41.81,,,percent of total billed charges,,,41.81,,,percent of total billed charges,,,41.81,,,percent of total billed charges,,,,,,,,,29.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,24.63,,,percent of total billed charges,,
DRONEDARONE,2500020268,CDM,637,RC,24414260,NDC,999,EAPG,,,,outpatient,facility,400,UN,41.81,41.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PRASUGREL 10 MG,2500020269,CDM,637,RC,5140724830,NDC,,,,,,inpatient,facility,10,UN,2.5,2.5,0.2,2.5,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,2.5,,,percent of total billed charges,,,1.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.47,,,percent of total billed charges,,
PRASUGREL 10 MG,2500020269,CDM,637,RC,5140724830,NDC,,,,,,outpatient,facility,10,UN,2.5,2.5,0.2,548.68,,1.77,,,percent of total billed charges,,,0.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.5,,,percent of total billed charges,,,1.57,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.92,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.5,,,fee schedule,,,2.5,,,percent of total billed charges,,,,,,,,,2.5,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.3,,,percent of total billed charges,,,1.38,,,percent of total billed charges,,,,,,,,,1.48,,,percent of total billed charges,,,548.68,,,per diem,,,2.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.5,,,percent of total billed charges,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.33,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.69,,,percent of total billed charges,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,0.93,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,2.5,,,percent of total billed charges,,,2.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.2,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,,,,,,,,,,,,,2.5,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,,,,,,,2.33,,,percent of total billed charges,,,,,,,,,,,,,,,2.33,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,1.88,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,2.5,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.47,,,percent of total billed charges,,
PRASUGREL 10 MG,2500020269,CDM,637,RC,5140724830,NDC,999,EAPG,,,,outpatient,facility,10,UN,2.5,2.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE/PRILOCAINE 30 GM,2500020270,CDM,637,RC,6373905466,NDC,,,,,,inpatient,facility,30,UN,28.88,28.88,2.31,28.88,,,,,,,,,,,,,,28.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.88,,,percent of total billed charges,,,,,,,,,28.88,,,percent of total billed charges,,,14.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.33,,,percent of total billed charges,,,,,,,,,,,,,,,28.88,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,28.88,,,percent of total billed charges,,,15.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,28.88,,,percent of total billed charges,,,,,,,,,,,,,,,2.31,,,percent of total billed charges,,,28.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.02,,,percent of total billed charges,,
LIDOCAINE/PRILOCAINE 30 GM,2500020270,CDM,637,RC,6373905466,NDC,,,,,,outpatient,facility,30,UN,28.88,28.88,2.31,548.68,,20.48,,,percent of total billed charges,,,7.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,28.88,,,percent of total billed charges,,,18.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,20.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,20.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,28.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,28.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,28.88,,,fee schedule,,,28.88,,,percent of total billed charges,,,,,,,,,28.88,,,percent of total billed charges,,,17.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.58,,,percent of total billed charges,,,,,,,,,,,,,,,15.6,,,percent of total billed charges,,,15.02,,,percent of total billed charges,,,15.88,,,percent of total billed charges,,,,,,,,,17.04,,,percent of total billed charges,,,548.68,,,per diem,,,28.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,28.88,,,percent of total billed charges,,,24.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.34,,,percent of total billed charges,,,28.88,,,percent of total billed charges,,,28.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.48,,,percent of total billed charges,,,23.37,,,percent of total billed charges,,,,,,,,,,,,,,,11.55,,,percent of total billed charges,,,,,,,,,10.69,,,percent of total billed charges,,,10.69,,,percent of total billed charges,,,,,,,,,28.88,,,percent of total billed charges,,,28.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.31,,,percent of total billed charges,,,28.88,,,percent of total billed charges,,,,,,,,,,,,,,,28.88,,,percent of total billed charges,,,28.88,,,percent of total billed charges,,,,,,,,,26.86,,,percent of total billed charges,,,,,,,,,,,,,,,26.86,,,percent of total billed charges,,,26.86,,,percent of total billed charges,,,26.86,,,percent of total billed charges,,,21.66,,,percent of total billed charges,,,28.88,,,percent of total billed charges,,,28.88,,,percent of total billed charges,,,28.88,,,percent of total billed charges,,,,,,,,,20.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.02,,,percent of total billed charges,,
LIDOCAINE/PRILOCAINE 30 GM,2500020270,CDM,637,RC,6373905466,NDC,999,EAPG,,,,outpatient,facility,30,UN,28.88,28.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VITAMIN D 1000 IU TAB,2500020286,CDM,637,RC,2055503300,NDC,,,,,,inpatient,facility,1000,UN,1.18,1.18,0.09,1.18,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,0.09,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,
VITAMIN D 1000 IU TAB,2500020286,CDM,637,RC,2055503300,NDC,,,,,,outpatient,facility,1000,UN,1.18,1.18,0.09,548.68,,0.84,,,percent of total billed charges,,,0.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.18,,,percent of total billed charges,,,0.74,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.43,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.18,,,fee schedule,,,1.18,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,0.7,,,percent of total billed charges,,,548.68,,,per diem,,,1.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.18,,,percent of total billed charges,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.63,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,0.44,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,1.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.09,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.7,,,percent of total billed charges,,
VITAMIN D 1000 IU TAB,2500020286,CDM,637,RC,2055503300,NDC,999,EAPG,,,,outpatient,facility,1000,UN,1.18,1.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALBUTEROL SULF INH SOL.042 3ML,2500020287,CDM,637,RC,487990425,NDC,,,,,,inpatient,facility,3,UN,5.48,5.48,0.44,5.48,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,5.48,,,percent of total billed charges,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.29,,,percent of total billed charges,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,4.66,,,percent of total billed charges,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,
ALBUTEROL SULF INH SOL.042 3ML,2500020287,CDM,637,RC,487990425,NDC,,,,,,outpatient,facility,3,UN,5.48,5.48,0.44,548.68,,3.89,,,percent of total billed charges,,,1.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.48,,,percent of total billed charges,,,3.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.48,,,fee schedule,,,5.48,,,percent of total billed charges,,,,,,,,,5.48,,,percent of total billed charges,,,3.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.96,,,percent of total billed charges,,,2.85,,,percent of total billed charges,,,3.01,,,percent of total billed charges,,,,,,,,,3.23,,,percent of total billed charges,,,548.68,,,per diem,,,5.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.48,,,percent of total billed charges,,,4.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.91,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,4.43,,,percent of total billed charges,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,,,,2.03,,,percent of total billed charges,,,2.03,,,percent of total billed charges,,,,,,,,,5.48,,,percent of total billed charges,,,5.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.44,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,5.1,,,percent of total billed charges,,,,,,,,,,,,,,,5.1,,,percent of total billed charges,,,5.1,,,percent of total billed charges,,,5.1,,,percent of total billed charges,,,4.11,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,5.48,,,percent of total billed charges,,,,,,,,,3.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.23,,,percent of total billed charges,,
ALBUTEROL SULF INH SOL.042 3ML,2500020287,CDM,637,RC,487990425,NDC,999,EAPG,,,,outpatient,facility,3,UN,5.48,5.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCA4 /PHENYLEPH0.5  TOP 5ML,2500031690,CDM,637,RC,7036000235,NDC,,,,,,inpatient,facility,5,UN,398.48,398.48,31.88,398.48,,,,,,,,,,,,,,398.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.48,,,percent of total billed charges,,,,,,,,,398.48,,,percent of total billed charges,,,203.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.09,,,percent of total billed charges,,,,,,,,,,,,,,,398.48,,,percent of total billed charges,,,338.71,,,percent of total billed charges,,,,,,,,,,,,,,,398.48,,,percent of total billed charges,,,211.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,398.48,,,percent of total billed charges,,,,,,,,,,,,,,,31.88,,,percent of total billed charges,,,398.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,398.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.78,,,percent of total billed charges,,
LIDOCA4 /PHENYLEPH0.5  TOP 5ML,2500031690,CDM,637,RC,7036000235,NDC,,,,,,outpatient,facility,5,UN,398.48,398.48,31.88,548.68,,282.56,,,percent of total billed charges,,,97.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,398.48,,,percent of total billed charges,,,249.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,280.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,280.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,398.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,145.84,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,398.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,398.48,,,fee schedule,,,398.48,,,percent of total billed charges,,,,,,,,,398.48,,,percent of total billed charges,,,244.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.92,,,percent of total billed charges,,,,,,,,,,,,,,,215.18,,,percent of total billed charges,,,207.21,,,percent of total billed charges,,,219.16,,,percent of total billed charges,,,,,,,,,235.1,,,percent of total billed charges,,,548.68,,,per diem,,,398.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,398.48,,,percent of total billed charges,,,338.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,211.63,,,percent of total billed charges,,,398.48,,,percent of total billed charges,,,398.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,268.81,,,percent of total billed charges,,,322.45,,,percent of total billed charges,,,,,,,,,,,,,,,159.39,,,percent of total billed charges,,,,,,,,,147.44,,,percent of total billed charges,,,147.44,,,percent of total billed charges,,,,,,,,,398.48,,,percent of total billed charges,,,398.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,398.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.88,,,percent of total billed charges,,,398.48,,,percent of total billed charges,,,,,,,,,,,,,,,398.48,,,percent of total billed charges,,,398.48,,,percent of total billed charges,,,,,,,,,370.67,,,percent of total billed charges,,,,,,,,,,,,,,,370.67,,,percent of total billed charges,,,370.67,,,percent of total billed charges,,,370.67,,,percent of total billed charges,,,298.86,,,percent of total billed charges,,,398.48,,,percent of total billed charges,,,398.48,,,percent of total billed charges,,,398.48,,,percent of total billed charges,,,,,,,,,279.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,234.78,,,percent of total billed charges,,
LIDOCA4 /PHENYLEPH0.5  TOP 5ML,2500031690,CDM,637,RC,7036000235,NDC,999,EAPG,,,,outpatient,facility,5,UN,398.48,398.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ROMIPLOSTIM 250 MCG INJ,2500031712,CDM,636,RC,J2796,HCPCS,5551322101,NDC,,,,inpatient,facility,250,GR,8652.34,8652.34,692.19,8652.34,,,,,,,,,,,,,,8652.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8652.34,,,percent of total billed charges,,,,,,,,,8652.34,,,percent of total billed charges,,,4417.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7369.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5191.4,,,percent of total billed charges,,,,,,,,,,,,,,,8652.34,,,percent of total billed charges,,,7354.49,,,percent of total billed charges,,,,,,,,,,,,,,,8652.34,,,percent of total billed charges,,,4595.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3460.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8652.34,,,percent of total billed charges,,,,,,,,,,,,,,,692.19,,,percent of total billed charges,,,8652.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8652.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5097.96,,,percent of total billed charges,,
ROMIPLOSTIM 250 MCG INJ,2500031712,CDM,636,RC,J2796,HCPCS,5551322101,NDC,,,,outpatient,facility,250,GR,8652.34,8652.34,52.58,8652.34,,6135.37,,,percent of total billed charges,,,2111.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8652.34,,,percent of total billed charges,,,130.85,,,fee schedule,,,123.79,,,fee schedule,,,,,,,,,123.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,8652.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3166.76,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,52.58,,,fee schedule,,,8652.34,,,fee schedule,,,8652.34,,,percent of total billed charges,,,,,,,,,8652.34,,,percent of total billed charges,,,5303.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6164.79,,,percent of total billed charges,,,,,,,,,,,,,,,96.03,,,fee schedule,,,96.03,,,fee schedule,,,96.03,,,fee schedule,,,,,,,,,5104.88,,,percent of total billed charges,,,548.68,,,per diem,,,8652.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8652.34,,,percent of total billed charges,,,7354.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4595.26,,,percent of total billed charges,,,8652.34,,,percent of total billed charges,,,8652.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5836.87,,,percent of total billed charges,,,7001.47,,,percent of total billed charges,,,,,,,,,,,,,,,3460.94,,,percent of total billed charges,,,,,,,,,218.67,,,fee schedule,,,157.35,,,fee schedule,,,,,,,,,8652.34,,,percent of total billed charges,,,8652.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8652.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,692.19,,,percent of total billed charges,,,8652.34,,,percent of total billed charges,,,,,,,,,,,,,,,8652.34,,,percent of total billed charges,,,8652.34,,,percent of total billed charges,,,,,,,,,93.45,,,fee schedule,,,,,,,,,,,,,,,80.99,,,fee schedule,,,107.99,,,fee schedule,,,60.74,,,fee schedule,,,104.62,,,fee schedule,,,8652.34,,,percent of total billed charges,,,8652.34,,,percent of total billed charges,,,8652.34,,,percent of total billed charges,,,,,,,,,6066.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4326.17,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5097.96,,,percent of total billed charges,,
ROMIPLOSTIM 250 MCG INJ,2500031712,CDM,636,RC,J2796,HCPCS,5551322101,NDC,999,EAPG,,outpatient,facility,250,GR,8652.34,8652.34,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CABAZITAXEL 60 MG,2500031733,CDM,636,RC,J9043,HCPCS,24582411,NDC,,,,inpatient,facility,1.5,ML,46683.55,46683.55,3734.68,46683.55,,,,,,,,,,,,,,46683.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46683.55,,,percent of total billed charges,,,,,,,,,46683.55,,,percent of total billed charges,,,23836.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39760.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28010.13,,,percent of total billed charges,,,,,,,,,,,,,,,46683.55,,,percent of total billed charges,,,39681.02,,,percent of total billed charges,,,,,,,,,,,,,,,46683.55,,,percent of total billed charges,,,24793.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18673.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,46683.55,,,percent of total billed charges,,,,,,,,,,,,,,,3734.68,,,percent of total billed charges,,,46683.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46683.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27505.95,,,percent of total billed charges,,
CABAZITAXEL 60 MG,2500031733,CDM,636,RC,J9043,HCPCS,24582411,NDC,,,,outpatient,facility,1.5,ML,46683.55,46683.55,133.53,46683.55,,33103.31,,,percent of total billed charges,,,,,,,,,46683.55,,,percent of total billed charges,,,279.72,,,fee schedule,,,264.63,,,fee schedule,,,,,,,,,264.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,46683.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,46683.55,,,fee schedule,,,46683.55,,,percent of total billed charges,,,,,,,,,46683.55,,,percent of total billed charges,,,28612.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33262.03,,,percent of total billed charges,,,,,,,,,,,,,,,210.45,,,fee schedule,,,210.45,,,fee schedule,,,210.45,,,fee schedule,,,,,,,,,27543.29,,,percent of total billed charges,,,548.68,,,per diem,,,46683.55,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,46683.55,,,percent of total billed charges,,,39681.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24793.63,,,percent of total billed charges,,,46683.55,,,percent of total billed charges,,,46683.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31492.72,,,percent of total billed charges,,,37776.33,,,percent of total billed charges,,,,,,,,,,,,,,,18673.42,,,percent of total billed charges,,,,,,,,,480.71,,,fee schedule,,,345.91,,,fee schedule,,,,,,,,,46683.55,,,percent of total billed charges,,,,,,,,,,,,,,,3734.68,,,percent of total billed charges,,,46683.55,,,percent of total billed charges,,,,,,,,,,,,,,,46683.55,,,percent of total billed charges,,,46683.55,,,percent of total billed charges,,,,,,,,,205.43,,,fee schedule,,,,,,,,,,,,,,,178.05,,,fee schedule,,,237.4,,,fee schedule,,,133.53,,,fee schedule,,,223.63,,,fee schedule,,,46683.55,,,percent of total billed charges,,,46683.55,,,percent of total billed charges,,,46683.55,,,percent of total billed charges,,,,,,,,,32729.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23341.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,27505.95,,,percent of total billed charges,,
CABAZITAXEL 60 MG,2500031733,CDM,636,RC,J9043,HCPCS,24582411,NDC,9276,APC,,outpatient,facility,1.5,ML,46683.55,46683.55,215.13,17086.18,,,,,,,,230.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,224.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.33,,,fee schedule,,,,,,,,,17086.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,224.09,,,fee schedule,,,,,,,,,,,,,,,235.29,,,fee schedule,,,235.29,,,fee schedule,,,,,,,,,224.09,,,fee schedule,,,224.09,,,fee schedule,,,235.29,,,fee schedule,,,,,,,,,,,,,,,336.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,224.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.13,,,fee schedule,,,239.78,,,fee schedule,,,235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.09,,,fee schedule,,,224.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,233.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,224.09,,,fee schedule,,,,,,,,,280.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,280.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,224.09,,,fee schedule,,,224.09,,,fee schedule,,,,,,,,,,,,,,,224.09,,,fee schedule,,,,,,,,,224.09,,,fee schedule,,,230.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.09,,,fee schedule,,,,,,,,,,,,,,,233.05,,,fee schedule,,,224.09,,,fee schedule,,,,,,,,,224.09,,,fee schedule,,,,,,,,,224.09,,,fee schedule,,,235.29,,,fee schedule,,,,,,,,
CABAZITAXEL 60 MG,2500031733,CDM,636,RC,J9043,HCPCS,24582411,NDC,463,EAPG,,outpatient,facility,1.5,ML,46683.55,46683.55,8302.02,12536.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12536.05,,,fee schedule,,,8302.02,,,fee schedule,,,11144.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8302.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8302.02,,,fee schedule,,,8302.02,,,fee schedule,,,8302.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,8302.02,,,fee schedule,,,,,,,,,,,,,,,8302.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DOCOSANOL 10  CR 2 GM TUBE,2500031735,CDM,637,RC,135020001,NDC,,,,,,inpatient,facility,2,UN,102.23,102.23,8.18,102.23,,,,,,,,,,,,,,102.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.23,,,percent of total billed charges,,,,,,,,,102.23,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.34,,,percent of total billed charges,,,,,,,,,,,,,,,102.23,,,percent of total billed charges,,,86.9,,,percent of total billed charges,,,,,,,,,,,,,,,102.23,,,percent of total billed charges,,,54.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,102.23,,,percent of total billed charges,,,,,,,,,,,,,,,8.18,,,percent of total billed charges,,,102.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,102.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.23,,,percent of total billed charges,,
DOCOSANOL 10  CR 2 GM TUBE,2500031735,CDM,637,RC,135020001,NDC,,,,,,outpatient,facility,2,UN,102.23,102.23,8.18,548.68,,72.49,,,percent of total billed charges,,,24.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,102.23,,,percent of total billed charges,,,64.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,71.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,71.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,102.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,37.42,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,102.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,102.23,,,fee schedule,,,102.23,,,percent of total billed charges,,,,,,,,,102.23,,,percent of total billed charges,,,62.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.84,,,percent of total billed charges,,,,,,,,,,,,,,,55.2,,,percent of total billed charges,,,53.16,,,percent of total billed charges,,,56.23,,,percent of total billed charges,,,,,,,,,60.32,,,percent of total billed charges,,,548.68,,,per diem,,,102.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,102.23,,,percent of total billed charges,,,86.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.29,,,percent of total billed charges,,,102.23,,,percent of total billed charges,,,102.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.96,,,percent of total billed charges,,,82.72,,,percent of total billed charges,,,,,,,,,,,,,,,40.89,,,percent of total billed charges,,,,,,,,,37.83,,,percent of total billed charges,,,37.83,,,percent of total billed charges,,,,,,,,,102.23,,,percent of total billed charges,,,102.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,102.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.18,,,percent of total billed charges,,,102.23,,,percent of total billed charges,,,,,,,,,,,,,,,102.23,,,percent of total billed charges,,,102.23,,,percent of total billed charges,,,,,,,,,95.09,,,percent of total billed charges,,,,,,,,,,,,,,,95.09,,,percent of total billed charges,,,95.09,,,percent of total billed charges,,,95.09,,,percent of total billed charges,,,76.67,,,percent of total billed charges,,,102.23,,,percent of total billed charges,,,102.23,,,percent of total billed charges,,,102.23,,,percent of total billed charges,,,,,,,,,71.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.12,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,60.23,,,percent of total billed charges,,
DOCOSANOL 10  CR 2 GM TUBE,2500031735,CDM,637,RC,135020001,NDC,999,EAPG,,,,outpatient,facility,2,UN,102.23,102.23,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PNEUMOCOCCAL 13 VACCINE 0.5 ML,2500031751,CDM,636,RC,90670,CPT,5197102,NDC,,,,inpatient,facility,0.5,UN,744.74,744.74,59.58,744.74,,,,,,,,,,,,,,744.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,744.74,,,percent of total billed charges,,,,,,,,,744.74,,,percent of total billed charges,,,380.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,634.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.84,,,percent of total billed charges,,,,,,,,,,,,,,,744.74,,,percent of total billed charges,,,633.03,,,percent of total billed charges,,,,,,,,,,,,,,,744.74,,,percent of total billed charges,,,395.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,297.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,744.74,,,percent of total billed charges,,,,,,,,,,,,,,,59.58,,,percent of total billed charges,,,744.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,744.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.8,,,percent of total billed charges,,
PNEUMOCOCCAL 13 VACCINE 0.5 ML,2500031751,CDM,636,RC,90670,CPT,5197102,NDC,,,,outpatient,facility,0.5,UN,744.74,744.74,59.58,744.74,,528.1,,,percent of total billed charges,,,142.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,744.74,,,percent of total billed charges,,,334.87,,,fee schedule,,,316.81,,,fee schedule,,,138.67,,,fee schedule,,,316.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,744.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.06,,,fee schedule,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,272.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,257.99,,,fee schedule,,,744.74,,,percent of total billed charges,,,138.67,,,fee schedule,,,744.74,,,percent of total billed charges,,,456.45,,,percent of total billed charges,,,145.6,,,fee schedule,,,145.6,,,fee schedule,,,,,,,,,141.5,,,fee schedule,,,138.67,,,fee schedule,,,145.6,,,fee schedule,,,530.63,,,percent of total billed charges,,,,,,,,,208,,,fee schedule,,,257.99,,,fee schedule,,,257.99,,,fee schedule,,,257.99,,,fee schedule,,,142.83,,,fee schedule,,,439.4,,,percent of total billed charges,,,548.68,,,per diem,,,744.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,744.74,,,percent of total billed charges,,,633.03,,,percent of total billed charges,,,133.82,,,fee schedule,,,148.38,,,fee schedule,,,148.58,,,fee schedule,,,395.53,,,percent of total billed charges,,,744.74,,,percent of total billed charges,,,744.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,138.67,,,fee schedule,,,138.67,,,fee schedule,,,502.4,,,percent of total billed charges,,,602.64,,,percent of total billed charges,,,,,,,,,147.16,,,fee schedule,,,297.9,,,percent of total billed charges,,,,,,,,,633.88,,,fee schedule,,,456.13,,,fee schedule,,,138.67,,,fee schedule,,,744.74,,,percent of total billed charges,,,173.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,173.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,59.58,,,percent of total billed charges,,,744.74,,,percent of total billed charges,,,138.67,,,fee schedule,,,208,,,fee schedule,,,744.74,,,percent of total billed charges,,,744.74,,,percent of total billed charges,,,138.67,,,fee schedule,,,270.89,,,fee schedule,,,138.67,,,fee schedule,,,142.83,,,fee schedule,,,234.79,,,fee schedule,,,313.05,,,fee schedule,,,176.08,,,fee schedule,,,267.73,,,fee schedule,,,744.74,,,percent of total billed charges,,,744.74,,,percent of total billed charges,,,744.74,,,percent of total billed charges,,,248.23,,,fee schedule,,,522.14,,,percent of total billed charges,,,138.67,,,fee schedule,,,147.87,,,fee schedule,,,138.67,,,fee schedule,,,138.67,,,fee schedule,,,141.5,,,fee schedule,,,372.37,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,141.5,,,fee schedule,,,145.6,,,fee schedule,,,438.8,,,percent of total billed charges,,
PNEUMOCOCCAL 13 VACCINE 0.5 ML,2500031751,CDM,636,RC,90670,CPT,5197102,NDC,415,EAPG,,outpatient,facility,0.5,UN,744.74,744.74,89.18,134.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.66,,,fee schedule,,,89.18,,,fee schedule,,,119.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.18,,,fee schedule,,,89.18,,,fee schedule,,,89.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,89.18,,,fee schedule,,,,,,,,,,,,,,,89.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIFAXIMIN 550 MG TAB,2500031757,CDM,637,RC,6564930303,NDC,,,,,,inpatient,facility,550,UN,179.69,179.69,14.38,179.69,,,,,,,,,,,,,,179.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.69,,,percent of total billed charges,,,,,,,,,179.69,,,percent of total billed charges,,,91.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.81,,,percent of total billed charges,,,,,,,,,,,,,,,179.69,,,percent of total billed charges,,,152.74,,,percent of total billed charges,,,,,,,,,,,,,,,179.69,,,percent of total billed charges,,,95.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,179.69,,,percent of total billed charges,,,,,,,,,,,,,,,14.38,,,percent of total billed charges,,,179.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,179.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.87,,,percent of total billed charges,,
RIFAXIMIN 550 MG TAB,2500031757,CDM,637,RC,6564930303,NDC,,,,,,outpatient,facility,550,UN,179.69,179.69,14.38,548.68,,127.42,,,percent of total billed charges,,,43.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,179.69,,,percent of total billed charges,,,112.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,126.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,126.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,179.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,65.77,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,179.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,179.69,,,fee schedule,,,179.69,,,percent of total billed charges,,,,,,,,,179.69,,,percent of total billed charges,,,110.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.03,,,percent of total billed charges,,,,,,,,,,,,,,,97.03,,,percent of total billed charges,,,93.44,,,percent of total billed charges,,,98.83,,,percent of total billed charges,,,,,,,,,106.02,,,percent of total billed charges,,,548.68,,,per diem,,,179.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,179.69,,,percent of total billed charges,,,152.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.43,,,percent of total billed charges,,,179.69,,,percent of total billed charges,,,179.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.22,,,percent of total billed charges,,,145.41,,,percent of total billed charges,,,,,,,,,,,,,,,71.88,,,percent of total billed charges,,,,,,,,,66.49,,,percent of total billed charges,,,66.49,,,percent of total billed charges,,,,,,,,,179.69,,,percent of total billed charges,,,179.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,179.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.38,,,percent of total billed charges,,,179.69,,,percent of total billed charges,,,,,,,,,,,,,,,179.69,,,percent of total billed charges,,,179.69,,,percent of total billed charges,,,,,,,,,167.15,,,percent of total billed charges,,,,,,,,,,,,,,,167.15,,,percent of total billed charges,,,167.15,,,percent of total billed charges,,,167.15,,,percent of total billed charges,,,134.77,,,percent of total billed charges,,,179.69,,,percent of total billed charges,,,179.69,,,percent of total billed charges,,,179.69,,,percent of total billed charges,,,,,,,,,125.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,105.87,,,percent of total billed charges,,
RIFAXIMIN 550 MG TAB,2500031757,CDM,637,RC,6564930303,NDC,999,EAPG,,,,outpatient,facility,550,UN,179.69,179.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMPHET ASP/AMPH/D-AMPH 10 MG,2500031762,CDM,637,RC,4778117601,NDC,,,,,,inpatient,facility,10,UN,5.64,5.64,0.45,5.64,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,5.64,,,percent of total billed charges,,,2.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.32,,,percent of total billed charges,,
AMPHET ASP/AMPH/D-AMPH 10 MG,2500031762,CDM,637,RC,4778117601,NDC,,,,,,outpatient,facility,10,UN,5.64,5.64,0.45,548.68,,4,,,percent of total billed charges,,,1.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.64,,,percent of total billed charges,,,3.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.96,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.06,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.64,,,fee schedule,,,5.64,,,percent of total billed charges,,,,,,,,,5.64,,,percent of total billed charges,,,3.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.02,,,percent of total billed charges,,,,,,,,,,,,,,,3.05,,,percent of total billed charges,,,2.93,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,3.33,,,percent of total billed charges,,,548.68,,,per diem,,,5.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.64,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,4.56,,,percent of total billed charges,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,2.09,,,percent of total billed charges,,,2.09,,,percent of total billed charges,,,,,,,,,5.64,,,percent of total billed charges,,,5.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.45,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,,,,,,,,,,,,,5.64,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,,,,,,,5.25,,,percent of total billed charges,,,,,,,,,,,,,,,5.25,,,percent of total billed charges,,,5.25,,,percent of total billed charges,,,5.25,,,percent of total billed charges,,,4.23,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,5.64,,,percent of total billed charges,,,,,,,,,3.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.32,,,percent of total billed charges,,
AMPHET ASP/AMPH/D-AMPH 10 MG,2500031762,CDM,637,RC,4778117601,NDC,999,EAPG,,,,outpatient,facility,10,UN,5.64,5.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MESALAMINE 1.2 GM TABCR,2500031769,CDM,637,RC,5409247612,NDC,,,,,,inpatient,facility,1.2,UN,30.88,30.88,2.47,30.88,,,,,,,,,,,,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.88,,,percent of total billed charges,,,,,,,,,30.88,,,percent of total billed charges,,,15.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.53,,,percent of total billed charges,,,,,,,,,,,,,,,30.88,,,percent of total billed charges,,,26.25,,,percent of total billed charges,,,,,,,,,,,,,,,30.88,,,percent of total billed charges,,,16.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,2.47,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.19,,,percent of total billed charges,,
MESALAMINE 1.2 GM TABCR,2500031769,CDM,637,RC,5409247612,NDC,,,,,,outpatient,facility,1.2,UN,30.88,30.88,2.47,548.68,,21.9,,,percent of total billed charges,,,7.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,30.88,,,percent of total billed charges,,,19.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,21.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,21.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,30.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,30.88,,,fee schedule,,,30.88,,,percent of total billed charges,,,,,,,,,30.88,,,percent of total billed charges,,,18.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22,,,percent of total billed charges,,,,,,,,,,,,,,,16.68,,,percent of total billed charges,,,16.06,,,percent of total billed charges,,,16.98,,,percent of total billed charges,,,,,,,,,18.22,,,percent of total billed charges,,,548.68,,,per diem,,,30.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,30.88,,,percent of total billed charges,,,26.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.4,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.83,,,percent of total billed charges,,,24.99,,,percent of total billed charges,,,,,,,,,,,,,,,12.35,,,percent of total billed charges,,,,,,,,,11.43,,,percent of total billed charges,,,11.43,,,percent of total billed charges,,,,,,,,,30.88,,,percent of total billed charges,,,30.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,30.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.47,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,,,,,,,,,,,,,30.88,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,,,,,,,28.72,,,percent of total billed charges,,,,,,,,,,,,,,,28.72,,,percent of total billed charges,,,28.72,,,percent of total billed charges,,,28.72,,,percent of total billed charges,,,23.16,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,30.88,,,percent of total billed charges,,,,,,,,,21.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.44,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.19,,,percent of total billed charges,,
MESALAMINE 1.2 GM TABCR,2500031769,CDM,637,RC,5409247612,NDC,999,EAPG,,,,outpatient,facility,1.2,UN,30.88,30.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SELENIUM SULF 1  SHAMP 210ML,2500031783,CDM,637,RC,536199553,NDC,,,,,,inpatient,facility,207,UN,9.54,9.54,0.76,9.54,,,,,,,,,,,,,,9.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.54,,,percent of total billed charges,,,,,,,,,9.54,,,percent of total billed charges,,,4.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.72,,,percent of total billed charges,,,,,,,,,,,,,,,9.54,,,percent of total billed charges,,,8.11,,,percent of total billed charges,,,,,,,,,,,,,,,9.54,,,percent of total billed charges,,,5.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.76,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.62,,,percent of total billed charges,,
SELENIUM SULF 1  SHAMP 210ML,2500031783,CDM,637,RC,536199553,NDC,,,,,,outpatient,facility,207,UN,9.54,9.54,0.76,548.68,,6.76,,,percent of total billed charges,,,2.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.54,,,percent of total billed charges,,,5.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.54,,,fee schedule,,,9.54,,,percent of total billed charges,,,,,,,,,9.54,,,percent of total billed charges,,,5.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,5.15,,,percent of total billed charges,,,4.96,,,percent of total billed charges,,,5.25,,,percent of total billed charges,,,,,,,,,5.63,,,percent of total billed charges,,,548.68,,,per diem,,,9.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.54,,,percent of total billed charges,,,8.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.07,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.44,,,percent of total billed charges,,,7.72,,,percent of total billed charges,,,,,,,,,,,,,,,3.82,,,percent of total billed charges,,,,,,,,,3.53,,,percent of total billed charges,,,3.53,,,percent of total billed charges,,,,,,,,,9.54,,,percent of total billed charges,,,9.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.76,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,,,,,,,,,,,,,9.54,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,,,,,,,8.87,,,percent of total billed charges,,,,,,,,,,,,,,,8.87,,,percent of total billed charges,,,8.87,,,percent of total billed charges,,,8.87,,,percent of total billed charges,,,7.15,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,9.54,,,percent of total billed charges,,,,,,,,,6.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.62,,,percent of total billed charges,,
SELENIUM SULF 1  SHAMP 210ML,2500031783,CDM,637,RC,536199553,NDC,999,EAPG,,,,outpatient,facility,207,UN,9.54,9.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM CITRATE 10 MEQ TAB,2500031788,CDM,637,RC,4254340701,NDC,,,,,,inpatient,facility,10,UN,8.09,8.09,0.65,8.09,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,,,,,,,,8.09,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.85,,,percent of total billed charges,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,,6.88,,,percent of total billed charges,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.77,,,percent of total billed charges,,
POTASSIUM CITRATE 10 MEQ TAB,2500031788,CDM,637,RC,4254340701,NDC,,,,,,outpatient,facility,10,UN,8.09,8.09,0.65,548.68,,5.74,,,percent of total billed charges,,,1.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.09,,,percent of total billed charges,,,5.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.96,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.09,,,fee schedule,,,8.09,,,percent of total billed charges,,,,,,,,,8.09,,,percent of total billed charges,,,4.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.76,,,percent of total billed charges,,,,,,,,,,,,,,,4.37,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,4.45,,,percent of total billed charges,,,,,,,,,4.77,,,percent of total billed charges,,,548.68,,,per diem,,,8.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.09,,,percent of total billed charges,,,6.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,,percent of total billed charges,,,6.55,,,percent of total billed charges,,,,,,,,,,,,,,,3.24,,,percent of total billed charges,,,,,,,,,2.99,,,percent of total billed charges,,,2.99,,,percent of total billed charges,,,,,,,,,8.09,,,percent of total billed charges,,,8.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.65,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,,,,,,,,,,,,,8.09,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,,,,,,,7.53,,,percent of total billed charges,,,,,,,,,,,,,,,7.53,,,percent of total billed charges,,,7.53,,,percent of total billed charges,,,7.53,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,8.09,,,percent of total billed charges,,,,,,,,,5.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.04,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.77,,,percent of total billed charges,,
POTASSIUM CITRATE 10 MEQ TAB,2500031788,CDM,637,RC,4254340701,NDC,999,EAPG,,,,outpatient,facility,10,UN,8.09,8.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SALIVA SUBSTITUTE 45 ML,2500031789,CDM,637,RC,4858200155,NDC,,,,,,inpatient,facility,44.3,UN,8.43,8.43,0.67,8.43,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,,,,,,,8.43,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.06,,,percent of total billed charges,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,7.17,,,percent of total billed charges,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,4.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.97,,,percent of total billed charges,,
SALIVA SUBSTITUTE 45 ML,2500031789,CDM,637,RC,4858200155,NDC,,,,,,outpatient,facility,44.3,UN,8.43,8.43,0.67,548.68,,5.98,,,percent of total billed charges,,,2.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,8.43,,,percent of total billed charges,,,5.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.09,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,8.43,,,fee schedule,,,8.43,,,percent of total billed charges,,,,,,,,,8.43,,,percent of total billed charges,,,5.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.01,,,percent of total billed charges,,,,,,,,,,,,,,,4.55,,,percent of total billed charges,,,4.38,,,percent of total billed charges,,,4.64,,,percent of total billed charges,,,,,,,,,4.97,,,percent of total billed charges,,,548.68,,,per diem,,,8.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,8.43,,,percent of total billed charges,,,7.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.48,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.69,,,percent of total billed charges,,,6.82,,,percent of total billed charges,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,3.12,,,percent of total billed charges,,,3.12,,,percent of total billed charges,,,,,,,,,8.43,,,percent of total billed charges,,,8.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.67,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,,,,,,,7.84,,,percent of total billed charges,,,,,,,,,,,,,,,7.84,,,percent of total billed charges,,,7.84,,,percent of total billed charges,,,7.84,,,percent of total billed charges,,,6.32,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,8.43,,,percent of total billed charges,,,,,,,,,5.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.21,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.97,,,percent of total billed charges,,
SALIVA SUBSTITUTE 45 ML,2500031789,CDM,637,RC,4858200155,NDC,999,EAPG,,,,outpatient,facility,44.3,UN,8.43,8.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPHEDRINE 50 MG/10 ML SYR,2500031794,CDM,250,RC,4202321625,NDC,,,,,,inpatient,facility,10,UN,187.28,187.28,14.98,187.28,,,,,,,,,,,,,,187.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.28,,,percent of total billed charges,,,,,,,,,187.28,,,percent of total billed charges,,,95.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.37,,,percent of total billed charges,,,,,,,,,,,,,,,187.28,,,percent of total billed charges,,,159.19,,,percent of total billed charges,,,,,,,,,,,,,,,187.28,,,percent of total billed charges,,,99.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,187.28,,,percent of total billed charges,,,,,,,,,,,,,,,14.98,,,percent of total billed charges,,,187.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,187.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.35,,,percent of total billed charges,,
EPHEDRINE 50 MG/10 ML SYR,2500031794,CDM,250,RC,4202321625,NDC,,,,,,outpatient,facility,10,UN,187.28,187.28,14.98,548.68,,132.8,,,percent of total billed charges,,,45.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,187.28,,,percent of total billed charges,,,117.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,131.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,131.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,187.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,68.54,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,187.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,187.28,,,fee schedule,,,187.28,,,percent of total billed charges,,,,,,,,,187.28,,,percent of total billed charges,,,114.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,110.5,,,percent of total billed charges,,,548.68,,,per diem,,,187.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,187.28,,,percent of total billed charges,,,159.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,99.46,,,percent of total billed charges,,,187.28,,,percent of total billed charges,,,187.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.34,,,percent of total billed charges,,,151.55,,,percent of total billed charges,,,,,,,,,,,,,,,74.91,,,percent of total billed charges,,,,,,,,,74.91,,,percent of total billed charges,,,74.91,,,percent of total billed charges,,,,,,,,,187.28,,,percent of total billed charges,,,187.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,187.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.98,,,percent of total billed charges,,,187.28,,,percent of total billed charges,,,,,,,,,,,,,,,187.28,,,percent of total billed charges,,,187.28,,,percent of total billed charges,,,,,,,,,74.91,,,percent of total billed charges,,,,,,,,,,,,,,,74.91,,,percent of total billed charges,,,74.91,,,percent of total billed charges,,,74.91,,,percent of total billed charges,,,140.46,,,percent of total billed charges,,,187.28,,,percent of total billed charges,,,187.28,,,percent of total billed charges,,,187.28,,,percent of total billed charges,,,,,,,,,131.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.64,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,110.35,,,percent of total billed charges,,
EPHEDRINE 50 MG/10 ML SYR,2500031794,CDM,250,RC,4202321625,NDC,999,EAPG,,,,outpatient,facility,10,UN,187.28,187.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DABIGATRANETEXILATE 150 MG CAP,2500031796,CDM,637,RC,597036082,NDC,,,,,,inpatient,facility,150,UN,10.92,10.92,0.87,10.92,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,10.92,,,percent of total billed charges,,,5.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.55,,,percent of total billed charges,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,9.28,,,percent of total billed charges,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,
DABIGATRANETEXILATE 150 MG CAP,2500031796,CDM,637,RC,597036082,NDC,,,,,,outpatient,facility,150,UN,10.92,10.92,0.87,548.68,,7.74,,,percent of total billed charges,,,2.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.92,,,percent of total billed charges,,,6.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.92,,,fee schedule,,,10.92,,,percent of total billed charges,,,,,,,,,10.92,,,percent of total billed charges,,,6.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.78,,,percent of total billed charges,,,,,,,,,,,,,,,5.9,,,percent of total billed charges,,,5.68,,,percent of total billed charges,,,6.01,,,percent of total billed charges,,,,,,,,,6.44,,,percent of total billed charges,,,548.68,,,per diem,,,10.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.92,,,percent of total billed charges,,,9.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.37,,,percent of total billed charges,,,8.84,,,percent of total billed charges,,,,,,,,,,,,,,,4.37,,,percent of total billed charges,,,,,,,,,4.04,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,10.92,,,percent of total billed charges,,,10.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.87,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,10.16,,,percent of total billed charges,,,,,,,,,,,,,,,10.16,,,percent of total billed charges,,,10.16,,,percent of total billed charges,,,10.16,,,percent of total billed charges,,,8.19,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.43,,,percent of total billed charges,,
DABIGATRANETEXILATE 150 MG CAP,2500031796,CDM,637,RC,597036082,NDC,999,EAPG,,,,outpatient,facility,150,UN,10.92,10.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DABIGATRAN 75 MG CAPS,2500031809,CDM,637,RC,597035556,NDC,,,,,,inpatient,facility,75,UN,10.92,10.92,0.87,10.92,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,10.92,,,percent of total billed charges,,,5.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.55,,,percent of total billed charges,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,9.28,,,percent of total billed charges,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,5.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.87,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.43,,,percent of total billed charges,,
DABIGATRAN 75 MG CAPS,2500031809,CDM,637,RC,597035556,NDC,,,,,,outpatient,facility,75,UN,10.92,10.92,0.87,548.68,,7.74,,,percent of total billed charges,,,2.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.92,,,percent of total billed charges,,,6.84,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.92,,,fee schedule,,,10.92,,,percent of total billed charges,,,,,,,,,10.92,,,percent of total billed charges,,,6.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.78,,,percent of total billed charges,,,,,,,,,,,,,,,5.9,,,percent of total billed charges,,,5.68,,,percent of total billed charges,,,6.01,,,percent of total billed charges,,,,,,,,,6.44,,,percent of total billed charges,,,548.68,,,per diem,,,10.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.92,,,percent of total billed charges,,,9.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.8,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.37,,,percent of total billed charges,,,8.84,,,percent of total billed charges,,,,,,,,,,,,,,,4.37,,,percent of total billed charges,,,,,,,,,4.04,,,percent of total billed charges,,,4.04,,,percent of total billed charges,,,,,,,,,10.92,,,percent of total billed charges,,,10.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.87,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,,,,,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,10.16,,,percent of total billed charges,,,,,,,,,,,,,,,10.16,,,percent of total billed charges,,,10.16,,,percent of total billed charges,,,10.16,,,percent of total billed charges,,,8.19,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,,,,,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.43,,,percent of total billed charges,,
DABIGATRAN 75 MG CAPS,2500031809,CDM,637,RC,597035556,NDC,999,EAPG,,,,outpatient,facility,75,UN,10.92,10.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DENOSUMAB INJ 120 MG,2500031811,CDM,636,RC,J0897,HCPCS,5551373001,NDC,,,,inpatient,facility,1.7,ML,10842.05,10842.05,867.36,10842.05,,,,,,,,,,,,,,10842.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10842.05,,,percent of total billed charges,,,,,,,,,10842.05,,,percent of total billed charges,,,5535.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9234.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6505.23,,,percent of total billed charges,,,,,,,,,,,,,,,10842.05,,,percent of total billed charges,,,9215.74,,,percent of total billed charges,,,,,,,,,,,,,,,10842.05,,,percent of total billed charges,,,5758.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4336.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10842.05,,,percent of total billed charges,,,,,,,,,,,,,,,867.36,,,percent of total billed charges,,,10842.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10842.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6388.14,,,percent of total billed charges,,
DENOSUMAB INJ 120 MG,2500031811,CDM,636,RC,J0897,HCPCS,5551373001,NDC,,,,outpatient,facility,1.7,ML,10842.05,10842.05,15.37,10842.05,,7688.1,,,percent of total billed charges,,,,,,,,,10842.05,,,percent of total billed charges,,,34.72,,,fee schedule,,,32.85,,,fee schedule,,,,,,,,,32.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,10842.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,10842.05,,,fee schedule,,,10842.05,,,percent of total billed charges,,,,,,,,,10842.05,,,percent of total billed charges,,,6645.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7724.96,,,percent of total billed charges,,,,,,,,,,,,,,,25.2,,,fee schedule,,,25.2,,,fee schedule,,,25.2,,,fee schedule,,,,,,,,,6396.81,,,percent of total billed charges,,,548.68,,,per diem,,,10842.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10842.05,,,percent of total billed charges,,,9215.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5758.21,,,percent of total billed charges,,,10842.05,,,percent of total billed charges,,,10842.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7314.05,,,percent of total billed charges,,,8773.39,,,percent of total billed charges,,,,,,,,,,,,,,,4336.82,,,percent of total billed charges,,,,,,,,,55.31,,,fee schedule,,,39.8,,,fee schedule,,,,,,,,,10842.05,,,percent of total billed charges,,,,,,,,,,,,,,,867.36,,,percent of total billed charges,,,10842.05,,,percent of total billed charges,,,,,,,,,,,,,,,10842.05,,,percent of total billed charges,,,10842.05,,,percent of total billed charges,,,,,,,,,23.64,,,fee schedule,,,,,,,,,,,,,,,20.48,,,fee schedule,,,27.31,,,fee schedule,,,15.37,,,fee schedule,,,27.75,,,fee schedule,,,10842.05,,,percent of total billed charges,,,10842.05,,,percent of total billed charges,,,10842.05,,,percent of total billed charges,,,,,,,,,7601.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5421.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6388.14,,,percent of total billed charges,,
DENOSUMAB INJ 120 MG,2500031811,CDM,636,RC,J0897,HCPCS,5551373001,NDC,9272,APC,,outpatient,facility,1.7,ML,10842.05,10842.05,26.55,3968.19,,,,,,,,28.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.94,,,fee schedule,,,,,,,,,3968.19,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,,,,,,,29.04,,,fee schedule,,,29.04,,,fee schedule,,,,,,,,,27.66,,,fee schedule,,,27.66,,,fee schedule,,,29.04,,,fee schedule,,,,,,,,,,,,,,,41.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.55,,,fee schedule,,,29.6,,,fee schedule,,,29.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,27.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,28.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,34.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,34.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,27.66,,,fee schedule,,,27.66,,,fee schedule,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,27.66,,,fee schedule,,,28.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,,,,,,,28.77,,,fee schedule,,,27.66,,,fee schedule,,,,,,,,,27.66,,,fee schedule,,,,,,,,,27.66,,,fee schedule,,,29.04,,,fee schedule,,,,,,,,
DENOSUMAB INJ 120 MG,2500031811,CDM,636,RC,J0897,HCPCS,5551373001,NDC,443,EAPG,,outpatient,facility,1.7,ML,10842.05,10842.05,1101.65,1663.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1663.49,,,fee schedule,,,1101.65,,,fee schedule,,,1478.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1101.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1101.65,,,fee schedule,,,1101.65,,,fee schedule,,,1101.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1101.65,,,fee schedule,,,,,,,,,,,,,,,1101.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FOSAPREPITANT 150 MG INJ,2500031814,CDM,636,RC,J1453,HCPCS,7220505401,NDC,,,,inpatient,facility,5,GR,1060.13,1060.13,84.81,1060.13,,,,,,,,,,,,,,1060.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1060.13,,,percent of total billed charges,,,,,,,,,1060.13,,,percent of total billed charges,,,541.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,902.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,636.08,,,percent of total billed charges,,,,,,,,,,,,,,,1060.13,,,percent of total billed charges,,,901.11,,,percent of total billed charges,,,,,,,,,,,,,,,1060.13,,,percent of total billed charges,,,563.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,424.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1060.13,,,percent of total billed charges,,,,,,,,,,,,,,,84.81,,,percent of total billed charges,,,1060.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1060.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,624.63,,,percent of total billed charges,,
FOSAPREPITANT 150 MG INJ,2500031814,CDM,636,RC,J1453,HCPCS,7220505401,NDC,,,,outpatient,facility,5,GR,1060.13,1060.13,0.14,1060.13,,751.74,,,percent of total billed charges,,,258.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1060.13,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,1060.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,388.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1060.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1060.13,,,fee schedule,,,1060.13,,,percent of total billed charges,,,,,,,,,1060.13,,,percent of total billed charges,,,649.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,755.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,fee schedule,,,0.14,,,fee schedule,,,0.14,,,fee schedule,,,,,,,,,625.48,,,percent of total billed charges,,,548.68,,,per diem,,,1060.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1060.13,,,percent of total billed charges,,,901.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,563.04,,,percent of total billed charges,,,1060.13,,,percent of total billed charges,,,1060.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,715.16,,,percent of total billed charges,,,857.86,,,percent of total billed charges,,,,,,,,,,,,,,,424.05,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1060.13,,,percent of total billed charges,,,1060.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1060.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,84.81,,,percent of total billed charges,,,1060.13,,,percent of total billed charges,,,,,,,,,,,,,,,1060.13,,,percent of total billed charges,,,1060.13,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.18,,,fee schedule,,,1060.13,,,percent of total billed charges,,,1060.13,,,percent of total billed charges,,,1060.13,,,percent of total billed charges,,,,,,,,,743.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.07,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,624.63,,,percent of total billed charges,,
FOSAPREPITANT 150 MG INJ,2500031814,CDM,636,RC,J1453,HCPCS,7220505401,NDC,435,EAPG,,outpatient,facility,5,GR,1060.13,1060.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEFLUNOMIDE 10 MG TAB,2500031824,CDM,637,RC,2315504303,NDC,,,,,,inpatient,facility,10,UN,149.69,149.69,11.98,149.69,,,,,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,149.69,,,percent of total billed charges,,,76.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.81,,,percent of total billed charges,,,,,,,,,,,,,,,149.69,,,percent of total billed charges,,,127.24,,,percent of total billed charges,,,,,,,,,,,,,,,149.69,,,percent of total billed charges,,,79.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,11.98,,,percent of total billed charges,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.2,,,percent of total billed charges,,
LEFLUNOMIDE 10 MG TAB,2500031824,CDM,637,RC,2315504303,NDC,,,,,,outpatient,facility,10,UN,149.69,149.69,11.98,548.68,,106.15,,,percent of total billed charges,,,36.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,149.69,,,percent of total billed charges,,,93.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,105.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,105.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,54.79,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,149.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,149.69,,,fee schedule,,,149.69,,,percent of total billed charges,,,,,,,,,149.69,,,percent of total billed charges,,,91.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.65,,,percent of total billed charges,,,,,,,,,,,,,,,80.83,,,percent of total billed charges,,,77.84,,,percent of total billed charges,,,82.33,,,percent of total billed charges,,,,,,,,,88.32,,,percent of total billed charges,,,548.68,,,per diem,,,149.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,149.69,,,percent of total billed charges,,,127.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.5,,,percent of total billed charges,,,149.69,,,percent of total billed charges,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,121.13,,,percent of total billed charges,,,,,,,,,,,,,,,59.88,,,percent of total billed charges,,,,,,,,,55.39,,,percent of total billed charges,,,55.39,,,percent of total billed charges,,,,,,,,,149.69,,,percent of total billed charges,,,149.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,149.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.98,,,percent of total billed charges,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,149.69,,,percent of total billed charges,,,149.69,,,percent of total billed charges,,,,,,,,,139.24,,,percent of total billed charges,,,,,,,,,,,,,,,139.24,,,percent of total billed charges,,,139.24,,,percent of total billed charges,,,139.24,,,percent of total billed charges,,,112.27,,,percent of total billed charges,,,149.69,,,percent of total billed charges,,,149.69,,,percent of total billed charges,,,149.69,,,percent of total billed charges,,,,,,,,,104.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,88.2,,,percent of total billed charges,,
LEFLUNOMIDE 10 MG TAB,2500031824,CDM,637,RC,2315504303,NDC,999,EAPG,,,,outpatient,facility,10,UN,149.69,149.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DENOSUMAB INJ 60 MG,2500031829,CDM,636,RC,J0897,HCPCS,5551371001,NDC,,,,inpatient,facility,1,ML,5894.2,5894.2,471.54,5894.2,,,,,,,,,,,,,,5894.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5894.2,,,percent of total billed charges,,,,,,,,,5894.2,,,percent of total billed charges,,,3009.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5020.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3536.52,,,percent of total billed charges,,,,,,,,,,,,,,,5894.2,,,percent of total billed charges,,,5010.07,,,percent of total billed charges,,,,,,,,,,,,,,,5894.2,,,percent of total billed charges,,,3130.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2357.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5894.2,,,percent of total billed charges,,,,,,,,,,,,,,,471.54,,,percent of total billed charges,,,5894.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5894.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3472.86,,,percent of total billed charges,,
DENOSUMAB INJ 60 MG,2500031829,CDM,636,RC,J0897,HCPCS,5551371001,NDC,,,,outpatient,facility,1,ML,5894.2,5894.2,15.37,5894.2,,4179.58,,,percent of total billed charges,,,,,,,,,5894.2,,,percent of total billed charges,,,34.72,,,fee schedule,,,32.85,,,fee schedule,,,,,,,,,32.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,5894.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,5894.2,,,fee schedule,,,5894.2,,,percent of total billed charges,,,,,,,,,5894.2,,,percent of total billed charges,,,3612.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4199.62,,,percent of total billed charges,,,,,,,,,,,,,,,25.2,,,fee schedule,,,25.2,,,fee schedule,,,25.2,,,fee schedule,,,,,,,,,3477.58,,,percent of total billed charges,,,548.68,,,per diem,,,5894.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5894.2,,,percent of total billed charges,,,5010.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3130.41,,,percent of total billed charges,,,5894.2,,,percent of total billed charges,,,5894.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3976.23,,,percent of total billed charges,,,4769.59,,,percent of total billed charges,,,,,,,,,,,,,,,2357.68,,,percent of total billed charges,,,,,,,,,55.31,,,fee schedule,,,39.8,,,fee schedule,,,,,,,,,5894.2,,,percent of total billed charges,,,,,,,,,,,,,,,471.54,,,percent of total billed charges,,,5894.2,,,percent of total billed charges,,,,,,,,,,,,,,,5894.2,,,percent of total billed charges,,,5894.2,,,percent of total billed charges,,,,,,,,,23.64,,,fee schedule,,,,,,,,,,,,,,,20.48,,,fee schedule,,,27.31,,,fee schedule,,,15.37,,,fee schedule,,,27.75,,,fee schedule,,,5894.2,,,percent of total billed charges,,,5894.2,,,percent of total billed charges,,,5894.2,,,percent of total billed charges,,,,,,,,,4132.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2947.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3472.86,,,percent of total billed charges,,
DENOSUMAB INJ 60 MG,2500031829,CDM,636,RC,J0897,HCPCS,5551371001,NDC,9272,APC,,outpatient,facility,1,ML,5894.2,5894.2,26.55,2157.28,,,,,,,,28.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.94,,,fee schedule,,,,,,,,,2157.28,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,,,,,,,29.04,,,fee schedule,,,29.04,,,fee schedule,,,,,,,,,27.66,,,fee schedule,,,27.66,,,fee schedule,,,29.04,,,fee schedule,,,,,,,,,,,,,,,41.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.55,,,fee schedule,,,29.6,,,fee schedule,,,29.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,27.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,28.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,34.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,34.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,27.66,,,fee schedule,,,27.66,,,fee schedule,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,27.66,,,fee schedule,,,28.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,,,,,,,28.77,,,fee schedule,,,27.66,,,fee schedule,,,,,,,,,27.66,,,fee schedule,,,,,,,,,27.66,,,fee schedule,,,29.04,,,fee schedule,,,,,,,,
DENOSUMAB INJ 60 MG,2500031829,CDM,636,RC,J0897,HCPCS,5551371001,NDC,443,EAPG,,outpatient,facility,1,ML,5894.2,5894.2,1101.65,1663.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1663.49,,,fee schedule,,,1101.65,,,fee schedule,,,1478.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1101.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1101.65,,,fee schedule,,,1101.65,,,fee schedule,,,1101.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1101.65,,,fee schedule,,,,,,,,,,,,,,,1101.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BRENTUXIMAB VEDOTIN 50 MG INJ,2500031832,CDM,636,RC,J9042,HCPCS,5114405001,NDC,,,,inpatient,facility,50,GR,35897.4,35897.4,2871.79,35897.4,,,,,,,,,,,,,,35897.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35897.4,,,percent of total billed charges,,,,,,,,,35897.4,,,percent of total billed charges,,,18329.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30573.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21538.44,,,percent of total billed charges,,,,,,,,,,,,,,,35897.4,,,percent of total billed charges,,,30512.79,,,percent of total billed charges,,,,,,,,,,,,,,,35897.4,,,percent of total billed charges,,,19065.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14358.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,35897.4,,,percent of total billed charges,,,,,,,,,,,,,,,2871.79,,,percent of total billed charges,,,35897.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35897.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21150.75,,,percent of total billed charges,,
BRENTUXIMAB VEDOTIN 50 MG INJ,2500031832,CDM,636,RC,J9042,HCPCS,5114405001,NDC,,,,outpatient,facility,50,GR,35897.4,35897.4,140.43,35897.4,,230.74,,,fee schedule,,,,,,,,,35897.4,,,percent of total billed charges,,,311,,,fee schedule,,,294.23,,,fee schedule,,,,,,,,,294.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,35897.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,35897.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,35897.4,,,fee schedule,,,35897.4,,,percent of total billed charges,,,,,,,,,35897.4,,,percent of total billed charges,,,22001.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25576.9,,,percent of total billed charges,,,,,,,,,,,,,,,230.61,,,fee schedule,,,230.61,,,fee schedule,,,230.61,,,fee schedule,,,,,,,,,21179.47,,,percent of total billed charges,,,548.68,,,per diem,,,35897.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,35897.4,,,percent of total billed charges,,,30512.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19065.11,,,percent of total billed charges,,,35897.4,,,percent of total billed charges,,,35897.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24216.39,,,percent of total billed charges,,,29048.18,,,percent of total billed charges,,,,,,,,,,,,,,,14358.96,,,percent of total billed charges,,,,,,,,,505.55,,,fee schedule,,,363.78,,,fee schedule,,,,,,,,,35897.4,,,percent of total billed charges,,,,,,,,,,,,,,,2871.79,,,percent of total billed charges,,,35897.4,,,percent of total billed charges,,,,,,,,,,,,,,,35897.4,,,percent of total billed charges,,,35897.4,,,percent of total billed charges,,,,,,,,,216.05,,,fee schedule,,,,,,,,,,,,,,,187.25,,,fee schedule,,,249.67,,,fee schedule,,,140.43,,,fee schedule,,,248.64,,,fee schedule,,,35897.4,,,percent of total billed charges,,,35897.4,,,percent of total billed charges,,,35897.4,,,percent of total billed charges,,,,,,,,,25167.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17948.7,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,21150.75,,,percent of total billed charges,,
BRENTUXIMAB VEDOTIN 50 MG INJ,2500031832,CDM,636,RC,J9042,HCPCS,5114405001,NDC,9287,APC,,outpatient,facility,50,GR,35897.4,35897.4,238.97,13138.45,,,,,,,,256.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,248.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,251.42,,,fee schedule,,,,,,,,,13138.45,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,248.93,,,fee schedule,,,,,,,,,,,,,,,261.38,,,fee schedule,,,261.38,,,fee schedule,,,,,,,,,248.93,,,fee schedule,,,248.93,,,fee schedule,,,261.38,,,fee schedule,,,,,,,,,,,,,,,373.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,248.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.97,,,fee schedule,,,266.36,,,fee schedule,,,261.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.93,,,fee schedule,,,248.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,258.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,248.93,,,fee schedule,,,,,,,,,311.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,311.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,248.93,,,fee schedule,,,248.93,,,fee schedule,,,,,,,,,,,,,,,248.93,,,fee schedule,,,,,,,,,248.93,,,fee schedule,,,256.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.93,,,fee schedule,,,,,,,,,,,,,,,258.89,,,fee schedule,,,248.93,,,fee schedule,,,,,,,,,248.93,,,fee schedule,,,,,,,,,248.93,,,fee schedule,,,261.38,,,fee schedule,,,,,,,,
BRENTUXIMAB VEDOTIN 50 MG INJ,2500031832,CDM,636,RC,J9042,HCPCS,5114405001,NDC,464,EAPG,,outpatient,facility,50,GR,35897.4,35897.4,8990.76,13576.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13576.05,,,fee schedule,,,8990.76,,,fee schedule,,,12069.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8990.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8990.76,,,fee schedule,,,8990.76,,,fee schedule,,,8990.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,8990.76,,,fee schedule,,,,,,,,,,,,,,,8990.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LACOSAMIDE 50 MG TAB,2500031833,CDM,637,RC,131247760,NDC,,,,,,inpatient,facility,50,UN,42.76,42.76,3.42,42.76,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,,,,,,,42.76,,,percent of total billed charges,,,21.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.66,,,percent of total billed charges,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,36.35,,,percent of total billed charges,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,22.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,3.42,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.19,,,percent of total billed charges,,
LACOSAMIDE 50 MG TAB,2500031833,CDM,637,RC,131247760,NDC,,,,,,outpatient,facility,50,UN,42.76,42.76,3.42,548.68,,30.32,,,percent of total billed charges,,,10.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,42.76,,,percent of total billed charges,,,26.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,30.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,30.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,15.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,42.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,42.76,,,fee schedule,,,42.76,,,percent of total billed charges,,,,,,,,,42.76,,,percent of total billed charges,,,26.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.47,,,percent of total billed charges,,,,,,,,,,,,,,,23.09,,,percent of total billed charges,,,22.24,,,percent of total billed charges,,,23.52,,,percent of total billed charges,,,,,,,,,25.23,,,percent of total billed charges,,,548.68,,,per diem,,,42.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,42.76,,,percent of total billed charges,,,36.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.71,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.85,,,percent of total billed charges,,,34.6,,,percent of total billed charges,,,,,,,,,,,,,,,17.1,,,percent of total billed charges,,,,,,,,,15.82,,,percent of total billed charges,,,15.82,,,percent of total billed charges,,,,,,,,,42.76,,,percent of total billed charges,,,42.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,42.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.42,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,39.78,,,percent of total billed charges,,,39.78,,,percent of total billed charges,,,32.07,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,42.76,,,percent of total billed charges,,,,,,,,,29.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,25.19,,,percent of total billed charges,,
LACOSAMIDE 50 MG TAB,2500031833,CDM,637,RC,131247760,NDC,999,EAPG,,,,outpatient,facility,50,UN,42.76,42.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PHENOBARBITAL 16.2 MG TAB,2500031841,CDM,637,RC,603516521,NDC,,,,,,inpatient,facility,16.2,UN,1.75,1.75,0.14,1.75,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,0.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.03,,,percent of total billed charges,,
PHENOBARBITAL 16.2 MG TAB,2500031841,CDM,637,RC,603516521,NDC,,,,,,outpatient,facility,16.2,UN,1.75,1.75,0.14,548.68,,1.24,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.75,,,percent of total billed charges,,,1.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.64,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.75,,,fee schedule,,,1.75,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,0.96,,,percent of total billed charges,,,,,,,,,1.03,,,percent of total billed charges,,,548.68,,,per diem,,,1.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.75,,,percent of total billed charges,,,1.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,,1.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,,,,0.65,,,percent of total billed charges,,,0.65,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.14,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,1.63,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,1.31,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,1.75,,,percent of total billed charges,,,,,,,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.03,,,percent of total billed charges,,
PHENOBARBITAL 16.2 MG TAB,2500031841,CDM,637,RC,603516521,NDC,999,EAPG,,,,outpatient,facility,16.2,UN,1.75,1.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ESTROGEN CONJ CR 30 GM,2500031849,CDM,637,RC,46087221,NDC,,,,,,inpatient,facility,30,UN,1485.17,1485.17,118.81,1485.17,,,,,,,,,,,,,,1485.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1485.17,,,percent of total billed charges,,,,,,,,,1485.17,,,percent of total billed charges,,,758.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1264.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,891.1,,,percent of total billed charges,,,,,,,,,,,,,,,1485.17,,,percent of total billed charges,,,1262.39,,,percent of total billed charges,,,,,,,,,,,,,,,1485.17,,,percent of total billed charges,,,788.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,594.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1485.17,,,percent of total billed charges,,,,,,,,,,,,,,,118.81,,,percent of total billed charges,,,1485.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1485.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,875.06,,,percent of total billed charges,,
ESTROGEN CONJ CR 30 GM,2500031849,CDM,637,RC,46087221,NDC,,,,,,outpatient,facility,30,UN,1485.17,1485.17,118.81,1485.17,,1053.13,,,percent of total billed charges,,,362.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1485.17,,,percent of total billed charges,,,930.76,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1044.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1044.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1485.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,543.57,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1485.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1485.17,,,fee schedule,,,1485.17,,,percent of total billed charges,,,,,,,,,1485.17,,,percent of total billed charges,,,910.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1058.18,,,percent of total billed charges,,,,,,,,,,,,,,,801.99,,,percent of total billed charges,,,772.29,,,percent of total billed charges,,,816.84,,,percent of total billed charges,,,,,,,,,876.25,,,percent of total billed charges,,,548.68,,,per diem,,,1485.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1485.17,,,percent of total billed charges,,,1262.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,788.77,,,percent of total billed charges,,,1485.17,,,percent of total billed charges,,,1485.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1001.9,,,percent of total billed charges,,,1201.8,,,percent of total billed charges,,,,,,,,,,,,,,,594.07,,,percent of total billed charges,,,,,,,,,549.51,,,percent of total billed charges,,,549.51,,,percent of total billed charges,,,,,,,,,1485.17,,,percent of total billed charges,,,1485.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1485.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,118.81,,,percent of total billed charges,,,1485.17,,,percent of total billed charges,,,,,,,,,,,,,,,1485.17,,,percent of total billed charges,,,1485.17,,,percent of total billed charges,,,,,,,,,1381.51,,,percent of total billed charges,,,,,,,,,,,,,,,1381.51,,,percent of total billed charges,,,1381.51,,,percent of total billed charges,,,1381.51,,,percent of total billed charges,,,1113.88,,,percent of total billed charges,,,1485.17,,,percent of total billed charges,,,1485.17,,,percent of total billed charges,,,1485.17,,,percent of total billed charges,,,,,,,,,1041.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,875.06,,,percent of total billed charges,,
ESTROGEN CONJ CR 30 GM,2500031849,CDM,637,RC,46087221,NDC,999,EAPG,,,,outpatient,facility,30,UN,1485.17,1485.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMOXICIL/CLAV 400MG/5ML UDC,2500031861,CDM,637,RC,6586253450,NDC,,,,,,inpatient,facility,5,UN,11.62,11.62,0.93,11.62,,,,,,,,,,,,,,11.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.62,,,percent of total billed charges,,,,,,,,,11.62,,,percent of total billed charges,,,5.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.97,,,percent of total billed charges,,,,,,,,,,,,,,,11.62,,,percent of total billed charges,,,9.88,,,percent of total billed charges,,,,,,,,,,,,,,,11.62,,,percent of total billed charges,,,6.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,11.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.85,,,percent of total billed charges,,
AMOXICIL/CLAV 400MG/5ML UDC,2500031861,CDM,637,RC,6586253450,NDC,,,,,,outpatient,facility,5,UN,11.62,11.62,0.93,548.68,,8.24,,,percent of total billed charges,,,2.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,11.62,,,percent of total billed charges,,,7.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,11.62,,,fee schedule,,,11.62,,,percent of total billed charges,,,,,,,,,11.62,,,percent of total billed charges,,,7.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.28,,,percent of total billed charges,,,,,,,,,,,,,,,6.27,,,percent of total billed charges,,,6.04,,,percent of total billed charges,,,6.39,,,percent of total billed charges,,,,,,,,,6.86,,,percent of total billed charges,,,548.68,,,per diem,,,11.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11.62,,,percent of total billed charges,,,9.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.17,,,percent of total billed charges,,,11.62,,,percent of total billed charges,,,11.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.84,,,percent of total billed charges,,,9.4,,,percent of total billed charges,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,,,,,,,4.3,,,percent of total billed charges,,,4.3,,,percent of total billed charges,,,,,,,,,11.62,,,percent of total billed charges,,,11.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.93,,,percent of total billed charges,,,11.62,,,percent of total billed charges,,,,,,,,,,,,,,,11.62,,,percent of total billed charges,,,11.62,,,percent of total billed charges,,,,,,,,,10.81,,,percent of total billed charges,,,,,,,,,,,,,,,10.81,,,percent of total billed charges,,,10.81,,,percent of total billed charges,,,10.81,,,percent of total billed charges,,,8.71,,,percent of total billed charges,,,11.62,,,percent of total billed charges,,,11.62,,,percent of total billed charges,,,11.62,,,percent of total billed charges,,,,,,,,,8.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.85,,,percent of total billed charges,,
AMOXICIL/CLAV 400MG/5ML UDC,2500031861,CDM,637,RC,6586253450,NDC,999,EAPG,,,,outpatient,facility,5,UN,11.62,11.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PERTUZUMAB 420 MG INJ,2500031876,CDM,636,RC,J9306,HCPCS,5024214501,NDC,,,,inpatient,facility,14,ML,21538.37,21538.37,1723.07,21538.37,,,,,,,,,,,,,,21538.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21538.37,,,percent of total billed charges,,,,,,,,,21538.37,,,percent of total billed charges,,,10997.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18344.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12923.02,,,percent of total billed charges,,,,,,,,,,,,,,,21538.37,,,percent of total billed charges,,,18307.61,,,percent of total billed charges,,,,,,,,,,,,,,,21538.37,,,percent of total billed charges,,,11439.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8615.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,21538.37,,,percent of total billed charges,,,,,,,,,,,,,,,1723.07,,,percent of total billed charges,,,21538.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21538.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12690.41,,,percent of total billed charges,,
PERTUZUMAB 420 MG INJ,2500031876,CDM,636,RC,J9306,HCPCS,5024214501,NDC,,,,outpatient,facility,14,ML,21538.37,21538.37,9.85,21538.37,,15.42,,,fee schedule,,,,,,,,,21538.37,,,percent of total billed charges,,,20.7,,,fee schedule,,,19.59,,,fee schedule,,,,,,,,,19.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,21538.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.64,,,fee schedule,,,21538.37,,,fee schedule,,,21538.37,,,percent of total billed charges,,,,,,,,,21538.37,,,percent of total billed charges,,,13200.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15346.09,,,percent of total billed charges,,,,,,,,,,,,,,,15.43,,,fee schedule,,,15.43,,,fee schedule,,,15.43,,,fee schedule,,,,,,,,,12707.64,,,percent of total billed charges,,,548.68,,,per diem,,,21538.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,21538.37,,,percent of total billed charges,,,18307.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11439.03,,,percent of total billed charges,,,21538.37,,,percent of total billed charges,,,21538.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14529.78,,,percent of total billed charges,,,17428.85,,,percent of total billed charges,,,,,,,,,,,,,,,8615.35,,,percent of total billed charges,,,,,,,,,35.48,,,fee schedule,,,25.53,,,fee schedule,,,,,,,,,21538.37,,,percent of total billed charges,,,,,,,,,,,,,,,1723.07,,,percent of total billed charges,,,21538.37,,,percent of total billed charges,,,,,,,,,,,,,,,21538.37,,,percent of total billed charges,,,21538.37,,,percent of total billed charges,,,,,,,,,15.16,,,fee schedule,,,,,,,,,,,,,,,13.14,,,fee schedule,,,17.52,,,fee schedule,,,9.85,,,fee schedule,,,16.54,,,fee schedule,,,21538.37,,,percent of total billed charges,,,21538.37,,,percent of total billed charges,,,21538.37,,,percent of total billed charges,,,,,,,,,15100.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10769.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,12690.41,,,percent of total billed charges,,
PERTUZUMAB 420 MG INJ,2500031876,CDM,636,RC,J9306,HCPCS,5024214501,NDC,1471,APC,,outpatient,facility,14,ML,21538.37,21538.37,15.54,7883.04,,,,,,,,16.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,16.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.35,,,fee schedule,,,,,,,,,7883.04,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,16.19,,,fee schedule,,,,,,,,,,,,,,,17,,,fee schedule,,,17,,,fee schedule,,,,,,,,,16.19,,,fee schedule,,,16.19,,,fee schedule,,,17,,,fee schedule,,,,,,,,,,,,,,,24.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,16.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.54,,,fee schedule,,,17.32,,,fee schedule,,,17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.19,,,fee schedule,,,16.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,16.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,16.19,,,fee schedule,,,,,,,,,20.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,20.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,16.19,,,fee schedule,,,16.19,,,fee schedule,,,,,,,,,,,,,,,16.19,,,fee schedule,,,,,,,,,16.19,,,fee schedule,,,16.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.19,,,fee schedule,,,,,,,,,,,,,,,16.84,,,fee schedule,,,16.19,,,fee schedule,,,,,,,,,16.19,,,fee schedule,,,,,,,,,16.19,,,fee schedule,,,17,,,fee schedule,,,,,,,,
PERTUZUMAB 420 MG INJ,2500031876,CDM,636,RC,J9306,HCPCS,5024214501,NDC,462,EAPG,,outpatient,facility,14,ML,21538.37,21538.37,16.19,24.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.45,,,fee schedule,,,16.19,,,fee schedule,,,21.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.19,,,fee schedule,,,16.19,,,fee schedule,,,16.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,16.19,,,fee schedule,,,,,,,,,,,,,,,16.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RASBURICASE 7.5 MG INJ,2500031894,CDM,636,RC,J2783,HCPCS,24515175,NDC,,,,inpatient,facility,7.5,GR,13659.06,13659.06,1092.72,13659.06,,,,,,,,,,,,,,13659.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13659.06,,,percent of total billed charges,,,,,,,,,13659.06,,,percent of total billed charges,,,6974.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11633.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8195.44,,,percent of total billed charges,,,,,,,,,,,,,,,13659.06,,,percent of total billed charges,,,11610.2,,,percent of total billed charges,,,,,,,,,,,,,,,13659.06,,,percent of total billed charges,,,7254.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5463.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13659.06,,,percent of total billed charges,,,,,,,,,,,,,,,1092.72,,,percent of total billed charges,,,13659.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13659.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8047.92,,,percent of total billed charges,,
RASBURICASE 7.5 MG INJ,2500031894,CDM,636,RC,J2783,HCPCS,24515175,NDC,,,,outpatient,facility,7.5,GR,13659.06,13659.06,226.64,13659.06,,9685.64,,,percent of total billed charges,,,,,,,,,13659.06,,,percent of total billed charges,,,481.43,,,fee schedule,,,455.47,,,fee schedule,,,,,,,,,455.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,13659.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13659.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13659.06,,,fee schedule,,,13659.06,,,percent of total billed charges,,,,,,,,,13659.06,,,percent of total billed charges,,,8371.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9732.08,,,percent of total billed charges,,,,,,,,,,,,,,,367.27,,,fee schedule,,,367.27,,,fee schedule,,,367.27,,,fee schedule,,,,,,,,,8058.85,,,percent of total billed charges,,,548.68,,,per diem,,,13659.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13659.06,,,percent of total billed charges,,,11610.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7254.33,,,percent of total billed charges,,,13659.06,,,percent of total billed charges,,,13659.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9214.4,,,percent of total billed charges,,,11052.91,,,percent of total billed charges,,,,,,,,,,,,,,,5463.62,,,percent of total billed charges,,,,,,,,,815.92,,,fee schedule,,,587.12,,,fee schedule,,,,,,,,,13659.06,,,percent of total billed charges,,,,,,,,,,,,,,,1092.72,,,percent of total billed charges,,,13659.06,,,percent of total billed charges,,,,,,,,,,,,,,,13659.06,,,percent of total billed charges,,,13659.06,,,percent of total billed charges,,,,,,,,,348.68,,,fee schedule,,,,,,,,,,,,,,,302.21,,,fee schedule,,,402.95,,,fee schedule,,,226.64,,,fee schedule,,,384.9,,,fee schedule,,,13659.06,,,percent of total billed charges,,,13659.06,,,percent of total billed charges,,,13659.06,,,percent of total billed charges,,,,,,,,,9576.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6829.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8047.92,,,percent of total billed charges,,
RASBURICASE 7.5 MG INJ,2500031894,CDM,636,RC,J2783,HCPCS,24515175,NDC,738,APC,,outpatient,facility,7.5,GR,13659.06,13659.06,355.17,4999.22,,,,,,,,381.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,369.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.67,,,fee schedule,,,,,,,,,4999.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,369.97,,,fee schedule,,,,,,,,,,,,,,,388.47,,,fee schedule,,,388.47,,,fee schedule,,,,,,,,,369.97,,,fee schedule,,,369.97,,,fee schedule,,,388.47,,,fee schedule,,,,,,,,,,,,,,,554.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,369.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.17,,,fee schedule,,,395.87,,,fee schedule,,,388.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,369.97,,,fee schedule,,,369.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,384.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,369.97,,,fee schedule,,,,,,,,,462.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,462.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,369.97,,,fee schedule,,,369.97,,,fee schedule,,,,,,,,,,,,,,,369.97,,,fee schedule,,,,,,,,,369.97,,,fee schedule,,,381.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,369.97,,,fee schedule,,,,,,,,,,,,,,,384.77,,,fee schedule,,,369.97,,,fee schedule,,,,,,,,,369.97,,,fee schedule,,,,,,,,,369.97,,,fee schedule,,,388.47,,,fee schedule,,,,,,,,
RASBURICASE 7.5 MG INJ,2500031894,CDM,636,RC,J2783,HCPCS,24515175,NDC,461,EAPG,,outpatient,facility,7.5,GR,13659.06,13659.06,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SENNA EXTRACT LIQ 5 ML UDC,2500031895,CDM,637,RC,4843321940,NDC,,,,,,inpatient,facility,5,UN,2.97,2.97,0.24,2.97,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,
SENNA EXTRACT LIQ 5 ML UDC,2500031895,CDM,637,RC,4843321940,NDC,,,,,,outpatient,facility,5,UN,2.97,2.97,0.24,548.68,,2.11,,,percent of total billed charges,,,0.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.97,,,percent of total billed charges,,,1.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.09,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.09,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.97,,,fee schedule,,,2.97,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,1.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.6,,,percent of total billed charges,,,1.54,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,1.75,,,percent of total billed charges,,,548.68,,,per diem,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.97,,,percent of total billed charges,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.58,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2.4,,,percent of total billed charges,,,,,,,,,,,,,,,1.19,,,percent of total billed charges,,,,,,,,,1.1,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,2.97,,,percent of total billed charges,,,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.24,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,2.76,,,percent of total billed charges,,,,,,,,,,,,,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.76,,,percent of total billed charges,,,2.23,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.75,,,percent of total billed charges,,
SENNA EXTRACT LIQ 5 ML UDC,2500031895,CDM,637,RC,4843321940,NDC,999,EAPG,,,,outpatient,facility,5,UN,2.97,2.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 0.5  PF 50 ML,2500031897,CDM,250,RC,J2003,HCPCS,409427801,NDC,,,,inpatient,facility,50,UN,14.26,14.26,1.14,14.26,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,14.26,,,percent of total billed charges,,,7.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.56,,,percent of total billed charges,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,12.12,,,percent of total billed charges,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,7.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.4,,,percent of total billed charges,,
LIDOCAINE 0.5  PF 50 ML,2500031897,CDM,250,RC,J2003,HCPCS,409427801,NDC,,,,outpatient,facility,50,UN,14.26,14.26,1.14,548.68,,10.11,,,percent of total billed charges,,,3.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.26,,,percent of total billed charges,,,8.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.26,,,fee schedule,,,14.26,,,percent of total billed charges,,,,,,,,,14.26,,,percent of total billed charges,,,8.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,8.41,,,percent of total billed charges,,,548.68,,,per diem,,,14.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.26,,,percent of total billed charges,,,12.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.57,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.62,,,percent of total billed charges,,,11.54,,,percent of total billed charges,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,,,,,,,5.28,,,percent of total billed charges,,,5.28,,,percent of total billed charges,,,,,,,,,14.26,,,percent of total billed charges,,,14.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.14,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,,,,,,,14.26,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,13.26,,,percent of total billed charges,,,,,,,,,,,,,,,13.26,,,percent of total billed charges,,,13.26,,,percent of total billed charges,,,13.26,,,percent of total billed charges,,,10.7,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,14.26,,,percent of total billed charges,,,,,,,,,10,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.4,,,percent of total billed charges,,
LIDOCAINE 0.5  PF 50 ML,2500031897,CDM,250,RC,J2003,HCPCS,409427801,NDC,999,EAPG,,outpatient,facility,50,UN,14.26,14.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARFILZOMIB INJ 60 MG,2500031898,CDM,636,RC,J9047,HCPCS,7607510101,NDC,,,,inpatient,facility,60,GR,10322.93,10322.93,825.83,10322.93,,,,,,,,,,,,,,10322.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10322.93,,,percent of total billed charges,,,,,,,,,10322.93,,,percent of total billed charges,,,5270.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8792.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6193.76,,,percent of total billed charges,,,,,,,,,,,,,,,10322.93,,,percent of total billed charges,,,8774.49,,,percent of total billed charges,,,,,,,,,,,,,,,10322.93,,,percent of total billed charges,,,5482.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4129.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10322.93,,,percent of total billed charges,,,,,,,,,,,,,,,825.83,,,percent of total billed charges,,,10322.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10322.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6082.27,,,percent of total billed charges,,
CARFILZOMIB INJ 60 MG,2500031898,CDM,636,RC,J9047,HCPCS,7607510101,NDC,,,,outpatient,facility,60,GR,10322.93,10322.93,30.05,10322.93,,47.18,,,fee schedule,,,,,,,,,10322.93,,,percent of total billed charges,,,64.42,,,fee schedule,,,60.95,,,fee schedule,,,,,,,,,60.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,10322.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,33.39,,,fee schedule,,,10322.93,,,fee schedule,,,10322.93,,,percent of total billed charges,,,,,,,,,10322.93,,,percent of total billed charges,,,6326.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7355.09,,,percent of total billed charges,,,,,,,,,,,,,,,47.09,,,fee schedule,,,47.09,,,fee schedule,,,47.09,,,fee schedule,,,,,,,,,6090.53,,,percent of total billed charges,,,548.68,,,per diem,,,10322.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10322.93,,,percent of total billed charges,,,8774.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5482.51,,,percent of total billed charges,,,10322.93,,,percent of total billed charges,,,10322.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6963.85,,,percent of total billed charges,,,8353.31,,,percent of total billed charges,,,,,,,,,,,,,,,4129.17,,,percent of total billed charges,,,,,,,,,108.18,,,fee schedule,,,77.85,,,fee schedule,,,,,,,,,10322.93,,,percent of total billed charges,,,,,,,,,,,,,,,825.83,,,percent of total billed charges,,,10322.93,,,percent of total billed charges,,,,,,,,,,,,,,,10322.93,,,percent of total billed charges,,,10322.93,,,percent of total billed charges,,,,,,,,,46.23,,,fee schedule,,,,,,,,,,,,,,,40.07,,,fee schedule,,,53.43,,,fee schedule,,,30.05,,,fee schedule,,,51.5,,,fee schedule,,,10322.93,,,percent of total billed charges,,,10322.93,,,percent of total billed charges,,,10322.93,,,percent of total billed charges,,,,,,,,,7237.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5161.47,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6082.27,,,percent of total billed charges,,
CARFILZOMIB INJ 60 MG,2500031898,CDM,636,RC,J9047,HCPCS,7607510101,NDC,9295,APC,,outpatient,facility,60,GR,10322.93,10322.93,49.89,3778.19,,,,,,,,53.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.49,,,fee schedule,,,,,,,,,3778.19,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,,,,,,,54.57,,,fee schedule,,,54.57,,,fee schedule,,,,,,,,,51.97,,,fee schedule,,,51.97,,,fee schedule,,,54.57,,,fee schedule,,,,,,,,,,,,,,,77.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.89,,,fee schedule,,,55.61,,,fee schedule,,,54.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,51.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,54.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,64.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,64.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,51.97,,,fee schedule,,,51.97,,,fee schedule,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,51.97,,,fee schedule,,,53.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,,,,,,,54.05,,,fee schedule,,,51.97,,,fee schedule,,,,,,,,,51.97,,,fee schedule,,,,,,,,,51.97,,,fee schedule,,,54.57,,,fee schedule,,,,,,,,
CARFILZOMIB INJ 60 MG,2500031898,CDM,636,RC,J9047,HCPCS,7607510101,NDC,460,EAPG,,outpatient,facility,60,GR,10322.93,10322.93,51.97,78.47,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.47,,,fee schedule,,,51.97,,,fee schedule,,,69.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,51.97,,,fee schedule,,,51.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IPILIMUMAB 50 MG INJ,2500031901,CDM,636,RC,J9228,HCPCS,3232711,NDC,,,,inpatient,facility,10,ML,28720.36,28720.36,2297.63,28720.36,,,,,,,,,,,,,,28720.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28720.36,,,percent of total billed charges,,,,,,,,,28720.36,,,percent of total billed charges,,,14664.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24461.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17232.22,,,percent of total billed charges,,,,,,,,,,,,,,,28720.36,,,percent of total billed charges,,,24412.31,,,percent of total billed charges,,,,,,,,,,,,,,,28720.36,,,percent of total billed charges,,,15253.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11488.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,28720.36,,,percent of total billed charges,,,,,,,,,,,,,,,2297.63,,,percent of total billed charges,,,28720.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28720.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16922.04,,,percent of total billed charges,,
IPILIMUMAB 50 MG INJ,2500031901,CDM,636,RC,J9228,HCPCS,3232711,NDC,,,,outpatient,facility,10,ML,28720.36,28720.36,111.32,28720.36,,20365.61,,,percent of total billed charges,,,,,,,,,28720.36,,,percent of total billed charges,,,229.46,,,fee schedule,,,217.09,,,fee schedule,,,,,,,,,217.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,28720.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,28720.36,,,fee schedule,,,28720.36,,,percent of total billed charges,,,,,,,,,28720.36,,,percent of total billed charges,,,17602.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20463.26,,,percent of total billed charges,,,,,,,,,,,,,,,172.42,,,fee schedule,,,172.42,,,fee schedule,,,172.42,,,fee schedule,,,,,,,,,16945.01,,,percent of total billed charges,,,548.68,,,per diem,,,28720.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,28720.36,,,percent of total billed charges,,,24412.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15253.38,,,percent of total billed charges,,,28720.36,,,percent of total billed charges,,,28720.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19374.75,,,percent of total billed charges,,,23240.52,,,percent of total billed charges,,,,,,,,,,,,,,,11488.14,,,percent of total billed charges,,,,,,,,,400.74,,,fee schedule,,,288.36,,,fee schedule,,,,,,,,,28720.36,,,percent of total billed charges,,,,,,,,,,,,,,,2297.63,,,percent of total billed charges,,,28720.36,,,percent of total billed charges,,,,,,,,,,,,,,,28720.36,,,percent of total billed charges,,,28720.36,,,percent of total billed charges,,,,,,,,,171.26,,,fee schedule,,,,,,,,,,,,,,,148.43,,,fee schedule,,,197.91,,,fee schedule,,,111.32,,,fee schedule,,,183.46,,,fee schedule,,,28720.36,,,percent of total billed charges,,,28720.36,,,percent of total billed charges,,,28720.36,,,percent of total billed charges,,,,,,,,,20135.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14360.18,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,16922.04,,,percent of total billed charges,,
IPILIMUMAB 50 MG INJ,2500031901,CDM,636,RC,J9228,HCPCS,3232711,NDC,9284,APC,,outpatient,facility,10,ML,28720.36,28720.36,172.85,10511.65,,,,,,,,185.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,180.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.85,,,fee schedule,,,,,,,,,10511.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,180.05,,,fee schedule,,,,,,,,,,,,,,,189.05,,,fee schedule,,,189.05,,,fee schedule,,,,,,,,,180.05,,,fee schedule,,,180.05,,,fee schedule,,,189.05,,,fee schedule,,,,,,,,,,,,,,,270.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,180.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.85,,,fee schedule,,,192.65,,,fee schedule,,,189.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.05,,,fee schedule,,,180.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,180.05,,,fee schedule,,,,,,,,,225.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,225.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,180.05,,,fee schedule,,,180.05,,,fee schedule,,,,,,,,,,,,,,,180.05,,,fee schedule,,,,,,,,,180.05,,,fee schedule,,,185.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.05,,,fee schedule,,,,,,,,,,,,,,,187.25,,,fee schedule,,,180.05,,,fee schedule,,,,,,,,,180.05,,,fee schedule,,,,,,,,,180.05,,,fee schedule,,,189.05,,,fee schedule,,,,,,,,
IPILIMUMAB 50 MG INJ,2500031901,CDM,636,RC,J9228,HCPCS,3232711,NDC,464,EAPG,,outpatient,facility,10,ML,28720.36,28720.36,8990.76,13576.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13576.05,,,fee schedule,,,8990.76,,,fee schedule,,,12069.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8990.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8990.76,,,fee schedule,,,8990.76,,,fee schedule,,,8990.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,8990.76,,,fee schedule,,,,,,,,,,,,,,,8990.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SP-NATALIZUMAB 300 MG INJ,2500031908,CDM,636,RC,J2323,HCPCS,6440600801,NDC,,,,inpatient,facility,300,UN,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-NATALIZUMAB 300 MG INJ,2500031908,CDM,636,RC,J2323,HCPCS,6440600801,NDC,,,,outpatient,facility,300,UN,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,31.24,,,fee schedule,,,29.56,,,fee schedule,,,,,,,,,29.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-NATALIZUMAB 300 MG INJ,2500031908,CDM,636,RC,J2323,HCPCS,6440600801,NDC,9126,APC,,outpatient,facility,300,UN,0.01,0.01,22.92,35.82,,,,,,,,24.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,23.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.88,,,fee schedule,,,,,,,,,,,,,,,25.07,,,fee schedule,,,25.07,,,fee schedule,,,,,,,,,23.88,,,fee schedule,,,23.88,,,fee schedule,,,25.07,,,fee schedule,,,,,,,,,,,,,,,35.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,23.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.92,,,fee schedule,,,25.55,,,fee schedule,,,25.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.88,,,fee schedule,,,23.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,24.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,23.88,,,fee schedule,,,,,,,,,29.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,23.88,,,fee schedule,,,23.88,,,fee schedule,,,,,,,,,,,,,,,23.88,,,fee schedule,,,,,,,,,23.88,,,fee schedule,,,24.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.88,,,fee schedule,,,,,,,,,,,,,,,24.84,,,fee schedule,,,23.88,,,fee schedule,,,,,,,,,23.88,,,fee schedule,,,,,,,,,23.88,,,fee schedule,,,25.07,,,fee schedule,,,,,,,,
SP-NATALIZUMAB 300 MG INJ,2500031908,CDM,636,RC,J2323,HCPCS,6440600801,NDC,463,EAPG,,outpatient,facility,300,UN,0.01,0.01,7053.67,10651.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10651.04,,,fee schedule,,,7053.67,,,fee schedule,,,9468.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SP-PEGFILGRASTIM 6 MG INJ,2500031909,CDM,636,RC,J2506,HCPCS,5551319001,NDC,,,,inpatient,facility,0.6,UN,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-PEGFILGRASTIM 6 MG INJ,2500031909,CDM,636,RC,J2506,HCPCS,5551319001,NDC,,,,outpatient,facility,0.6,UN,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,71.56,,,fee schedule,,,67.7,,,fee schedule,,,,,,,,,67.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-PEGFILGRASTIM 6 MG INJ,2500031909,CDM,636,RC,J2506,HCPCS,5551319001,NDC,9436,APC,,outpatient,facility,0.6,UN,0.01,0.01,19.18,29.97,,,,,,,,20.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,,,,,,,20.98,,,fee schedule,,,20.98,,,fee schedule,,,,,,,,,19.98,,,fee schedule,,,19.98,,,fee schedule,,,20.98,,,fee schedule,,,,,,,,,,,,,,,29.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.18,,,fee schedule,,,21.38,,,fee schedule,,,20.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,19.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,20.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,24.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,19.98,,,fee schedule,,,19.98,,,fee schedule,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,19.98,,,fee schedule,,,20.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,,,,,,,20.78,,,fee schedule,,,19.98,,,fee schedule,,,,,,,,,19.98,,,fee schedule,,,,,,,,,19.98,,,fee schedule,,,20.98,,,fee schedule,,,,,,,,
SP-PEGFILGRASTIM 6 MG INJ,2500031909,CDM,636,RC,J2506,HCPCS,5551319001,NDC,461,EAPG,,outpatient,facility,0.6,UN,0.01,0.01,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADO-TRASTUZUMAB 100 MG INJ,2500031910,CDM,636,RC,J9354,HCPCS,5024208801,NDC,,,,inpatient,facility,100,GR,12971.21,12971.21,1037.7,12971.21,,,,,,,,,,,,,,12971.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12971.21,,,percent of total billed charges,,,,,,,,,12971.21,,,percent of total billed charges,,,6623.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11047.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7782.73,,,percent of total billed charges,,,,,,,,,,,,,,,12971.21,,,percent of total billed charges,,,11025.53,,,percent of total billed charges,,,,,,,,,,,,,,,12971.21,,,percent of total billed charges,,,6889.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5188.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,12971.21,,,percent of total billed charges,,,,,,,,,,,,,,,1037.7,,,percent of total billed charges,,,12971.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12971.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7642.64,,,percent of total billed charges,,
ADO-TRASTUZUMAB 100 MG INJ,2500031910,CDM,636,RC,J9354,HCPCS,5024208801,NDC,,,,outpatient,facility,100,GR,12971.21,12971.21,24.37,12971.21,,38.44,,,fee schedule,,,,,,,,,12971.21,,,percent of total billed charges,,,51.97,,,fee schedule,,,49.17,,,fee schedule,,,,,,,,,49.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,12971.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,33.25,,,fee schedule,,,12971.21,,,fee schedule,,,12971.21,,,percent of total billed charges,,,,,,,,,12971.21,,,percent of total billed charges,,,7950.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9241.99,,,percent of total billed charges,,,,,,,,,,,,,,,38.37,,,fee schedule,,,38.37,,,fee schedule,,,38.37,,,fee schedule,,,,,,,,,7653.01,,,percent of total billed charges,,,548.68,,,per diem,,,12971.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,12971.21,,,percent of total billed charges,,,11025.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6889.01,,,percent of total billed charges,,,12971.21,,,percent of total billed charges,,,12971.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8750.38,,,percent of total billed charges,,,10496.3,,,percent of total billed charges,,,,,,,,,,,,,,,5188.48,,,percent of total billed charges,,,,,,,,,87.71,,,fee schedule,,,63.12,,,fee schedule,,,,,,,,,12971.21,,,percent of total billed charges,,,,,,,,,,,,,,,1037.7,,,percent of total billed charges,,,12971.21,,,percent of total billed charges,,,,,,,,,,,,,,,12971.21,,,percent of total billed charges,,,12971.21,,,percent of total billed charges,,,,,,,,,37.49,,,fee schedule,,,,,,,,,,,,,,,32.49,,,fee schedule,,,43.32,,,fee schedule,,,24.37,,,fee schedule,,,41.56,,,fee schedule,,,12971.21,,,percent of total billed charges,,,12971.21,,,percent of total billed charges,,,12971.21,,,percent of total billed charges,,,,,,,,,9094.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6485.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,7642.64,,,percent of total billed charges,,
ADO-TRASTUZUMAB 100 MG INJ,2500031910,CDM,636,RC,J9354,HCPCS,5024208801,NDC,9131,APC,,outpatient,facility,100,GR,12971.21,12971.21,39.33,4747.46,,,,,,,,42.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,40.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.38,,,fee schedule,,,,,,,,,4747.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,40.97,,,fee schedule,,,,,,,,,,,,,,,43.02,,,fee schedule,,,43.02,,,fee schedule,,,,,,,,,40.97,,,fee schedule,,,40.97,,,fee schedule,,,43.02,,,fee schedule,,,,,,,,,,,,,,,61.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,40.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.33,,,fee schedule,,,43.84,,,fee schedule,,,43.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.97,,,fee schedule,,,40.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,42.61,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,40.97,,,fee schedule,,,,,,,,,51.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,51.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,40.97,,,fee schedule,,,40.97,,,fee schedule,,,,,,,,,,,,,,,40.97,,,fee schedule,,,,,,,,,40.97,,,fee schedule,,,42.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.97,,,fee schedule,,,,,,,,,,,,,,,42.61,,,fee schedule,,,40.97,,,fee schedule,,,,,,,,,40.97,,,fee schedule,,,,,,,,,40.97,,,fee schedule,,,43.02,,,fee schedule,,,,,,,,
ADO-TRASTUZUMAB 100 MG INJ,2500031910,CDM,636,RC,J9354,HCPCS,5024208801,NDC,462,EAPG,,outpatient,facility,100,GR,12971.21,12971.21,4530.01,6840.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6840.32,,,fee schedule,,,4530.01,,,fee schedule,,,6081.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ADO-TRASTUZUMAB 160 MG INJ,2500031911,CDM,636,RC,J9354,HCPCS,5024208701,NDC,,,,inpatient,facility,160,GR,20753.9,20753.9,1660.31,20753.9,,,,,,,,,,,,,,20753.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20753.9,,,percent of total billed charges,,,,,,,,,20753.9,,,percent of total billed charges,,,10596.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17676.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12452.34,,,percent of total billed charges,,,,,,,,,,,,,,,20753.9,,,percent of total billed charges,,,17640.82,,,percent of total billed charges,,,,,,,,,,,,,,,20753.9,,,percent of total billed charges,,,11022.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8301.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,20753.9,,,percent of total billed charges,,,,,,,,,,,,,,,1660.31,,,percent of total billed charges,,,20753.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20753.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12228.2,,,percent of total billed charges,,
ADO-TRASTUZUMAB 160 MG INJ,2500031911,CDM,636,RC,J9354,HCPCS,5024208701,NDC,,,,outpatient,facility,160,GR,20753.9,20753.9,24.37,20753.9,,38.44,,,fee schedule,,,,,,,,,20753.9,,,percent of total billed charges,,,51.97,,,fee schedule,,,49.17,,,fee schedule,,,,,,,,,49.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,20753.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,33.25,,,fee schedule,,,20753.9,,,fee schedule,,,20753.9,,,percent of total billed charges,,,,,,,,,20753.9,,,percent of total billed charges,,,12720.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14787.15,,,percent of total billed charges,,,,,,,,,,,,,,,38.37,,,fee schedule,,,38.37,,,fee schedule,,,38.37,,,fee schedule,,,,,,,,,12244.8,,,percent of total billed charges,,,548.68,,,per diem,,,20753.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,20753.9,,,percent of total billed charges,,,17640.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11022.4,,,percent of total billed charges,,,20753.9,,,percent of total billed charges,,,20753.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14000.58,,,percent of total billed charges,,,16794.06,,,percent of total billed charges,,,,,,,,,,,,,,,8301.56,,,percent of total billed charges,,,,,,,,,87.71,,,fee schedule,,,63.12,,,fee schedule,,,,,,,,,20753.9,,,percent of total billed charges,,,,,,,,,,,,,,,1660.31,,,percent of total billed charges,,,20753.9,,,percent of total billed charges,,,,,,,,,,,,,,,20753.9,,,percent of total billed charges,,,20753.9,,,percent of total billed charges,,,,,,,,,37.49,,,fee schedule,,,,,,,,,,,,,,,32.49,,,fee schedule,,,43.32,,,fee schedule,,,24.37,,,fee schedule,,,41.56,,,fee schedule,,,20753.9,,,percent of total billed charges,,,20753.9,,,percent of total billed charges,,,20753.9,,,percent of total billed charges,,,,,,,,,14550.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10376.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,12228.2,,,percent of total billed charges,,
ADO-TRASTUZUMAB 160 MG INJ,2500031911,CDM,636,RC,J9354,HCPCS,5024208701,NDC,9131,APC,,outpatient,facility,160,GR,20753.9,20753.9,39.33,7595.93,,,,,,,,42.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,40.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.38,,,fee schedule,,,,,,,,,7595.93,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,40.97,,,fee schedule,,,,,,,,,,,,,,,43.02,,,fee schedule,,,43.02,,,fee schedule,,,,,,,,,40.97,,,fee schedule,,,40.97,,,fee schedule,,,43.02,,,fee schedule,,,,,,,,,,,,,,,61.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,40.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.33,,,fee schedule,,,43.84,,,fee schedule,,,43.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.97,,,fee schedule,,,40.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,42.61,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,40.97,,,fee schedule,,,,,,,,,51.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,51.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,40.97,,,fee schedule,,,40.97,,,fee schedule,,,,,,,,,,,,,,,40.97,,,fee schedule,,,,,,,,,40.97,,,fee schedule,,,42.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.97,,,fee schedule,,,,,,,,,,,,,,,42.61,,,fee schedule,,,40.97,,,fee schedule,,,,,,,,,40.97,,,fee schedule,,,,,,,,,40.97,,,fee schedule,,,43.02,,,fee schedule,,,,,,,,
ADO-TRASTUZUMAB 160 MG INJ,2500031911,CDM,636,RC,J9354,HCPCS,5024208701,NDC,462,EAPG,,outpatient,facility,160,GR,20753.9,20753.9,4530.01,6840.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6840.32,,,fee schedule,,,4530.01,,,fee schedule,,,6081.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SP-DENOSUMAB INJ 120 MG,2500031925,CDM,636,RC,J0897,HCPCS,5551371001,NDC,,,,inpatient,facility,1.7,UN,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-DENOSUMAB INJ 120 MG,2500031925,CDM,636,RC,J0897,HCPCS,5551371001,NDC,,,,outpatient,facility,1.7,UN,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,34.72,,,fee schedule,,,32.85,,,fee schedule,,,,,,,,,32.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-DENOSUMAB INJ 120 MG,2500031925,CDM,636,RC,J0897,HCPCS,5551371001,NDC,9272,APC,,outpatient,facility,1.7,UN,0.01,0.01,26.55,41.49,,,,,,,,28.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.94,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,,,,,,,29.04,,,fee schedule,,,29.04,,,fee schedule,,,,,,,,,27.66,,,fee schedule,,,27.66,,,fee schedule,,,29.04,,,fee schedule,,,,,,,,,,,,,,,41.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.55,,,fee schedule,,,29.6,,,fee schedule,,,29.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,27.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,28.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,34.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,34.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,27.66,,,fee schedule,,,27.66,,,fee schedule,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,27.66,,,fee schedule,,,28.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,,,,,,,28.77,,,fee schedule,,,27.66,,,fee schedule,,,,,,,,,27.66,,,fee schedule,,,,,,,,,27.66,,,fee schedule,,,29.04,,,fee schedule,,,,,,,,
SP-DENOSUMAB INJ 120 MG,2500031925,CDM,636,RC,J0897,HCPCS,5551371001,NDC,443,EAPG,,outpatient,facility,1.7,UN,0.01,0.01,1101.65,1663.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1663.49,,,fee schedule,,,1101.65,,,fee schedule,,,1478.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1101.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1101.65,,,fee schedule,,,1101.65,,,fee schedule,,,1101.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1101.65,,,fee schedule,,,,,,,,,,,,,,,1101.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SP-EPOETIN ALFA 1000 U INJ,2500031927,CDM,636,RC,J0885,HCPCS,69130510,NDC,,,,inpatient,facility,1000,UN,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-EPOETIN ALFA 1000 U INJ,2500031927,CDM,636,RC,J0885,HCPCS,69130510,NDC,,,,outpatient,facility,1000,UN,0.01,0.01,0.01,548.68,,8.27,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,10.55,,,fee schedule,,,9.98,,,fee schedule,,,,,,,,,9.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-EPOETIN ALFA 1000 U INJ,2500031927,CDM,636,RC,J0885,HCPCS,69130510,NDC,1686,APC,,outpatient,facility,1000,UN,0.01,0.01,6.2,9.69,,,,,,,,6.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,6.78,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,6.46,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,,,,,,,,9.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.2,,,fee schedule,,,6.91,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,6.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,6.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,8.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,6.46,,,fee schedule,,,6.46,,,fee schedule,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,6.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,fee schedule,,,,,,,,,,,,,,,6.72,,,fee schedule,,,6.46,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,,,,,,,6.46,,,fee schedule,,,6.78,,,fee schedule,,,,,,,,
SP-EPOETIN ALFA 1000 U INJ,2500031927,CDM,636,RC,J0885,HCPCS,69130510,NDC,437,EAPG,,outpatient,facility,1000,UN,0.01,0.01,156.28,235.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.98,,,fee schedule,,,156.28,,,fee schedule,,,209.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SP-IMMUNE GLOBULIN 10   IV USE,2500031932,CDM,636,RC,J1569,HCPCS,944270002,NDC,,,,inpatient,facility,5,GR,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-IMMUNE GLOBULIN 10   IV USE,2500031932,CDM,636,RC,J1569,HCPCS,944270002,NDC,,,,outpatient,facility,5,GR,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,58.5,,,fee schedule,,,55.35,,,fee schedule,,,,,,,,,55.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-IMMUNE GLOBULIN 10   IV USE,2500031932,CDM,636,RC,J1569,HCPCS,944270002,NDC,944,APC,,outpatient,facility,5,GR,0.01,0.01,44.6,69.69,,,,,,,,47.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,46.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.46,,,fee schedule,,,,,,,,,,,,,,,48.78,,,fee schedule,,,48.78,,,fee schedule,,,,,,,,,46.46,,,fee schedule,,,46.46,,,fee schedule,,,48.78,,,fee schedule,,,,,,,,,,,,,,,69.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.6,,,fee schedule,,,49.71,,,fee schedule,,,48.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.46,,,fee schedule,,,46.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,48.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,46.46,,,fee schedule,,,,,,,,,58.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,58.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,46.46,,,fee schedule,,,46.46,,,fee schedule,,,,,,,,,,,,,,,46.46,,,fee schedule,,,,,,,,,46.46,,,fee schedule,,,47.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.46,,,fee schedule,,,,,,,,,,,,,,,48.32,,,fee schedule,,,46.46,,,fee schedule,,,,,,,,,46.46,,,fee schedule,,,,,,,,,46.46,,,fee schedule,,,48.78,,,fee schedule,,,,,,,,
SP-IMMUNE GLOBULIN 10   IV USE,2500031932,CDM,636,RC,J1569,HCPCS,944270002,NDC,461,EAPG,,outpatient,facility,5,GR,0.01,0.01,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SP-ZOLEDR ACID 5 MG/100 ML BTL,2500031945,CDM,636,RC,J3489,HCPCS,5511168852,NDC,,,,inpatient,facility,100,UN,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-ZOLEDR ACID 5 MG/100 ML BTL,2500031945,CDM,636,RC,J3489,HCPCS,5511168852,NDC,,,,outpatient,facility,100,UN,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-ZOLEDR ACID 5 MG/100 ML BTL,2500031945,CDM,636,RC,J3489,HCPCS,5511168852,NDC,435,EAPG,,outpatient,facility,100,UN,0.01,0.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SP-ZOLEDRONIC ACID 4 MG VIAL,2500031946,CDM,636,RC,J3489,HCPCS,1672924231,NDC,,,,inpatient,facility,4,UN,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-ZOLEDRONIC ACID 4 MG VIAL,2500031946,CDM,636,RC,J3489,HCPCS,1672924231,NDC,,,,outpatient,facility,4,UN,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-ZOLEDRONIC ACID 4 MG VIAL,2500031946,CDM,636,RC,J3489,HCPCS,1672924231,NDC,435,EAPG,,outpatient,facility,4,UN,0.01,0.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPRENORPHIN SL FILM 8 MG/2 MG,2500031952,CDM,636,RC,J0574,HCPCS,4778135703,NDC,,,,inpatient,facility,1,UN,29.01,29.01,2.32,29.01,,,,,,,,,,,,,,29.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.01,,,percent of total billed charges,,,,,,,,,29.01,,,percent of total billed charges,,,14.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.41,,,percent of total billed charges,,,,,,,,,,,,,,,29.01,,,percent of total billed charges,,,24.66,,,percent of total billed charges,,,,,,,,,,,,,,,29.01,,,percent of total billed charges,,,15.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,29.01,,,percent of total billed charges,,,,,,,,,,,,,,,2.32,,,percent of total billed charges,,,29.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.09,,,percent of total billed charges,,
BUPRENORPHIN SL FILM 8 MG/2 MG,2500031952,CDM,636,RC,J0574,HCPCS,4778135703,NDC,,,,outpatient,facility,1,UN,29.01,29.01,2.32,548.68,,20.57,,,percent of total billed charges,,,7.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,29.01,,,percent of total billed charges,,,11.47,,,fee schedule,,,10.86,,,fee schedule,,,,,,,,,10.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,29.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.62,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,29.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,29.01,,,fee schedule,,,29.01,,,percent of total billed charges,,,,,,,,,29.01,,,percent of total billed charges,,,17.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.67,,,percent of total billed charges,,,,,,,,,,,,,,,7.91,,,fee schedule,,,7.91,,,fee schedule,,,7.91,,,fee schedule,,,,,,,,,17.12,,,percent of total billed charges,,,548.68,,,per diem,,,29.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,29.01,,,percent of total billed charges,,,24.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.41,,,percent of total billed charges,,,29.01,,,percent of total billed charges,,,29.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.57,,,percent of total billed charges,,,23.47,,,percent of total billed charges,,,,,,,,,,,,,,,11.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,29.01,,,percent of total billed charges,,,29.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,29.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.32,,,percent of total billed charges,,,29.01,,,percent of total billed charges,,,,,,,,,,,,,,,29.01,,,percent of total billed charges,,,29.01,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,21.76,,,percent of total billed charges,,,29.01,,,percent of total billed charges,,,29.01,,,percent of total billed charges,,,29.01,,,percent of total billed charges,,,,,,,,,20.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.51,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17.09,,,percent of total billed charges,,
BUPRENORPHIN SL FILM 8 MG/2 MG,2500031952,CDM,636,RC,J0574,HCPCS,4778135703,NDC,435,EAPG,,outpatient,facility,1,UN,29.01,29.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LACOSAMIDE 200 MG/20 ML VIAL,2500031955,CDM,636,RC,C9254,HCPCS,131181067,NDC,,,,inpatient,facility,20,UN,319.01,319.01,25.52,319.01,,,,,,,,,,,,,,319.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.01,,,percent of total billed charges,,,,,,,,,319.01,,,percent of total billed charges,,,162.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,271.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.41,,,percent of total billed charges,,,,,,,,,,,,,,,319.01,,,percent of total billed charges,,,271.16,,,percent of total billed charges,,,,,,,,,,,,,,,319.01,,,percent of total billed charges,,,169.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,319.01,,,percent of total billed charges,,,,,,,,,,,,,,,25.52,,,percent of total billed charges,,,319.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,319.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.96,,,percent of total billed charges,,
LACOSAMIDE 200 MG/20 ML VIAL,2500031955,CDM,636,RC,C9254,HCPCS,131181067,NDC,,,,outpatient,facility,20,UN,319.01,319.01,25.52,548.68,,226.21,,,percent of total billed charges,,,77.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,319.01,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,319.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,116.76,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,319.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,319.01,,,fee schedule,,,319.01,,,percent of total billed charges,,,,,,,,,319.01,,,percent of total billed charges,,,195.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,188.22,,,percent of total billed charges,,,548.68,,,per diem,,,319.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,319.01,,,percent of total billed charges,,,271.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,169.43,,,percent of total billed charges,,,319.01,,,percent of total billed charges,,,319.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.2,,,percent of total billed charges,,,258.14,,,percent of total billed charges,,,,,,,,,,,,,,,127.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,319.01,,,percent of total billed charges,,,319.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,319.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.52,,,percent of total billed charges,,,319.01,,,percent of total billed charges,,,,,,,,,,,,,,,319.01,,,percent of total billed charges,,,319.01,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,239.26,,,percent of total billed charges,,,319.01,,,percent of total billed charges,,,319.01,,,percent of total billed charges,,,319.01,,,percent of total billed charges,,,,,,,,,223.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,187.96,,,percent of total billed charges,,
LACOSAMIDE 200 MG/20 ML VIAL,2500031955,CDM,636,RC,C9254,HCPCS,131181067,NDC,999,EAPG,,outpatient,facility,20,UN,319.01,319.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SP-LEUPROLIDE LUPRON 22.5MG KT,2500031963,CDM,636,RC,J9217,HCPCS,74334603,NDC,,,,inpatient,facility,22.5,UN,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-LEUPROLIDE LUPRON 22.5MG KT,2500031963,CDM,636,RC,J9217,HCPCS,74334603,NDC,,,,outpatient,facility,22.5,UN,0.01,0.01,0.01,548.68,,185.66,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,234.34,,,fee schedule,,,221.7,,,fee schedule,,,,,,,,,221.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-LEUPROLIDE LUPRON 22.5MG KT,2500031963,CDM,636,RC,J9217,HCPCS,74334603,NDC,9217,APC,,outpatient,facility,22.5,UN,0.01,0.01,173.56,271.18,,,,,,,,186.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,189.83,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,180.79,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,,,,,,,,271.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.56,,,fee schedule,,,193.45,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,180.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,188.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,225.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,225.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,180.79,,,fee schedule,,,180.79,,,fee schedule,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,186.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,188.02,,,fee schedule,,,180.79,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,
SP-LEUPROLIDE LUPRON 22.5MG KT,2500031963,CDM,636,RC,J9217,HCPCS,74334603,NDC,434,EAPG,,outpatient,facility,22.5,UN,0.01,0.01,380.24,574.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,574.16,,,fee schedule,,,380.24,,,fee schedule,,,510.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,380.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,380.24,,,fee schedule,,,380.24,,,fee schedule,,,380.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,380.24,,,fee schedule,,,,,,,,,,,,,,,380.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TICAGRELOR 90 MG TAB,2500031965,CDM,637,RC,186077739,NDC,,,,,,inpatient,facility,90,UN,24.81,24.81,1.98,24.81,,,,,,,,,,,,,,24.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.81,,,percent of total billed charges,,,,,,,,,24.81,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.89,,,percent of total billed charges,,,,,,,,,,,,,,,24.81,,,percent of total billed charges,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,24.81,,,percent of total billed charges,,,13.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,24.81,,,percent of total billed charges,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,24.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.62,,,percent of total billed charges,,
TICAGRELOR 90 MG TAB,2500031965,CDM,637,RC,186077739,NDC,,,,,,outpatient,facility,90,UN,24.81,24.81,1.98,548.68,,17.59,,,percent of total billed charges,,,6.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,24.81,,,percent of total billed charges,,,15.55,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,17.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,17.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,24.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,24.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,24.81,,,fee schedule,,,24.81,,,percent of total billed charges,,,,,,,,,24.81,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.68,,,percent of total billed charges,,,,,,,,,,,,,,,13.4,,,percent of total billed charges,,,12.9,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,,,,,,,14.64,,,percent of total billed charges,,,548.68,,,per diem,,,24.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,24.81,,,percent of total billed charges,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.18,,,percent of total billed charges,,,24.81,,,percent of total billed charges,,,24.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.74,,,percent of total billed charges,,,20.08,,,percent of total billed charges,,,,,,,,,,,,,,,9.92,,,percent of total billed charges,,,,,,,,,9.18,,,percent of total billed charges,,,9.18,,,percent of total billed charges,,,,,,,,,24.81,,,percent of total billed charges,,,24.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.98,,,percent of total billed charges,,,24.81,,,percent of total billed charges,,,,,,,,,,,,,,,24.81,,,percent of total billed charges,,,24.81,,,percent of total billed charges,,,,,,,,,23.08,,,percent of total billed charges,,,,,,,,,,,,,,,23.08,,,percent of total billed charges,,,23.08,,,percent of total billed charges,,,23.08,,,percent of total billed charges,,,18.61,,,percent of total billed charges,,,24.81,,,percent of total billed charges,,,24.81,,,percent of total billed charges,,,24.81,,,percent of total billed charges,,,,,,,,,17.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.62,,,percent of total billed charges,,
TICAGRELOR 90 MG TAB,2500031965,CDM,637,RC,186077739,NDC,999,EAPG,,,,outpatient,facility,90,UN,24.81,24.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE LIPOSOM 133 MG SYR,2500031984,CDM,636,RC,C9290,HCPCS,6525013309,NDC,,,,inpatient,facility,10,ML,519.75,519.75,41.58,519.75,,,,,,,,,,,,,,519.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,519.75,,,percent of total billed charges,,,,,,,,,519.75,,,percent of total billed charges,,,265.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,442.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,311.85,,,percent of total billed charges,,,,,,,,,,,,,,,519.75,,,percent of total billed charges,,,441.79,,,percent of total billed charges,,,,,,,,,,,,,,,519.75,,,percent of total billed charges,,,276.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,519.75,,,percent of total billed charges,,,,,,,,,,,,,,,41.58,,,percent of total billed charges,,,519.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,519.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.24,,,percent of total billed charges,,
BUPIVACAINE LIPOSOM 133 MG SYR,2500031984,CDM,636,RC,C9290,HCPCS,6525013309,NDC,,,,outpatient,facility,10,ML,519.75,519.75,41.58,548.68,,368.55,,,percent of total billed charges,,,126.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,519.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,519.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,190.23,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,519.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,519.75,,,fee schedule,,,519.75,,,percent of total billed charges,,,,,,,,,519.75,,,percent of total billed charges,,,318.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,306.65,,,percent of total billed charges,,,548.68,,,per diem,,,519.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,519.75,,,percent of total billed charges,,,441.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,276.04,,,percent of total billed charges,,,519.75,,,percent of total billed charges,,,519.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.62,,,percent of total billed charges,,,420.58,,,percent of total billed charges,,,,,,,,,,,,,,,207.9,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,519.75,,,percent of total billed charges,,,519.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,519.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,41.58,,,percent of total billed charges,,,519.75,,,percent of total billed charges,,,,,,,,,,,,,,,519.75,,,percent of total billed charges,,,519.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,389.81,,,percent of total billed charges,,,519.75,,,percent of total billed charges,,,519.75,,,percent of total billed charges,,,519.75,,,percent of total billed charges,,,,,,,,,364.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,259.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,306.24,,,percent of total billed charges,,
BUPIVACAINE LIPOSOM 133 MG SYR,2500031984,CDM,636,RC,C9290,HCPCS,6525013309,NDC,999,EAPG,,outpatient,facility,10,ML,519.75,519.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TBO-FILGRASTIM 480 MCG INJ,2500031986,CDM,636,RC,J1447,HCPCS,6345991211,NDC,,,,inpatient,facility,0.8,UN,1583.54,1583.54,126.68,1583.54,,,,,,,,,,,,,,1583.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1583.54,,,percent of total billed charges,,,,,,,,,1583.54,,,percent of total billed charges,,,808.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1348.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,950.12,,,percent of total billed charges,,,,,,,,,,,,,,,1583.54,,,percent of total billed charges,,,1346.01,,,percent of total billed charges,,,,,,,,,,,,,,,1583.54,,,percent of total billed charges,,,841.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,633.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1583.54,,,percent of total billed charges,,,,,,,,,,,,,,,126.68,,,percent of total billed charges,,,1583.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1583.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,933.02,,,percent of total billed charges,,
TBO-FILGRASTIM 480 MCG INJ,2500031986,CDM,636,RC,J1447,HCPCS,6345991211,NDC,,,,outpatient,facility,0.8,UN,1583.54,1583.54,0.27,1583.54,,0.41,,,fee schedule,,,,,,,,,1583.54,,,percent of total billed charges,,,0.52,,,fee schedule,,,0.49,,,fee schedule,,,,,,,,,0.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1583.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1583.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1583.54,,,fee schedule,,,1583.54,,,percent of total billed charges,,,,,,,,,1583.54,,,percent of total billed charges,,,970.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1128.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,fee schedule,,,0.44,,,fee schedule,,,0.44,,,fee schedule,,,,,,,,,934.29,,,percent of total billed charges,,,548.68,,,per diem,,,1583.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1583.54,,,percent of total billed charges,,,1346.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,841.02,,,percent of total billed charges,,,1583.54,,,percent of total billed charges,,,1583.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1068.26,,,percent of total billed charges,,,1281.4,,,percent of total billed charges,,,,,,,,,,,,,,,633.42,,,percent of total billed charges,,,,,,,,,0.96,,,fee schedule,,,0.69,,,fee schedule,,,,,,,,,1583.54,,,percent of total billed charges,,,,,,,,,,,,,,,126.68,,,percent of total billed charges,,,1583.54,,,percent of total billed charges,,,,,,,,,,,,,,,1583.54,,,percent of total billed charges,,,1583.54,,,percent of total billed charges,,,,,,,,,0.41,,,fee schedule,,,,,,,,,,,,,,,0.35,,,fee schedule,,,0.47,,,fee schedule,,,0.27,,,fee schedule,,,0.42,,,fee schedule,,,1583.54,,,percent of total billed charges,,,1583.54,,,percent of total billed charges,,,1583.54,,,percent of total billed charges,,,,,,,,,1110.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,791.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,933.02,,,percent of total billed charges,,
TBO-FILGRASTIM 480 MCG INJ,2500031986,CDM,636,RC,J1447,HCPCS,6345991211,NDC,1748,APC,,outpatient,facility,0.8,UN,1583.54,1583.54,0.38,579.58,,,,,,,,0.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,579.58,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.42,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,0.4,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,,,,,,,,0.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,fee schedule,,,0.43,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.4,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,0.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.42,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,
TBO-FILGRASTIM 480 MCG INJ,2500031986,CDM,636,RC,J1447,HCPCS,6345991211,NDC,438,EAPG,,outpatient,facility,0.8,UN,1583.54,1583.54,332.92,502.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,502.71,,,fee schedule,,,332.92,,,fee schedule,,,446.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SEVELAMER CARBONATE 800 MG,2500031988,CDM,637,RC,955105027,NDC,,,,,,inpatient,facility,800,UN,5.61,5.61,0.45,5.61,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,5.61,,,percent of total billed charges,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.37,,,percent of total billed charges,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,2.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.31,,,percent of total billed charges,,
SEVELAMER CARBONATE 800 MG,2500031988,CDM,637,RC,955105027,NDC,,,,,,outpatient,facility,800,UN,5.61,5.61,0.45,548.68,,3.98,,,percent of total billed charges,,,1.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,5.61,,,percent of total billed charges,,,3.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,3.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,3.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.05,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,5.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,5.61,,,fee schedule,,,5.61,,,percent of total billed charges,,,,,,,,,5.61,,,percent of total billed charges,,,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4,,,percent of total billed charges,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,,2.92,,,percent of total billed charges,,,3.09,,,percent of total billed charges,,,,,,,,,3.31,,,percent of total billed charges,,,548.68,,,per diem,,,5.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,5.61,,,percent of total billed charges,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.78,,,percent of total billed charges,,,4.54,,,percent of total billed charges,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,,,,2.08,,,percent of total billed charges,,,2.08,,,percent of total billed charges,,,,,,,,,5.61,,,percent of total billed charges,,,5.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.45,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,,,,,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,5.22,,,percent of total billed charges,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,5.22,,,percent of total billed charges,,,4.21,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,5.61,,,percent of total billed charges,,,,,,,,,3.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3.31,,,percent of total billed charges,,
SEVELAMER CARBONATE 800 MG,2500031988,CDM,637,RC,955105027,NDC,999,EAPG,,,,outpatient,facility,800,UN,5.61,5.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VORTIOXETINE 10MG TAB,2500031993,CDM,637,RC,6476472030,NDC,,,,,,inpatient,facility,5,UN,51.31,51.31,4.1,51.31,,,,,,,,,,,,,,51.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.31,,,percent of total billed charges,,,,,,,,,51.31,,,percent of total billed charges,,,26.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.79,,,percent of total billed charges,,,,,,,,,,,,,,,51.31,,,percent of total billed charges,,,43.61,,,percent of total billed charges,,,,,,,,,,,,,,,51.31,,,percent of total billed charges,,,27.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,51.31,,,percent of total billed charges,,,,,,,,,,,,,,,4.1,,,percent of total billed charges,,,51.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.23,,,percent of total billed charges,,
VORTIOXETINE 10MG TAB,2500031993,CDM,637,RC,6476472030,NDC,,,,,,outpatient,facility,5,UN,51.31,51.31,4.1,548.68,,36.38,,,percent of total billed charges,,,12.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,51.31,,,percent of total billed charges,,,32.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,36.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,36.07,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,51.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,18.78,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,51.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,51.31,,,fee schedule,,,51.31,,,percent of total billed charges,,,,,,,,,51.31,,,percent of total billed charges,,,31.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.56,,,percent of total billed charges,,,,,,,,,,,,,,,27.71,,,percent of total billed charges,,,26.68,,,percent of total billed charges,,,28.22,,,percent of total billed charges,,,,,,,,,30.27,,,percent of total billed charges,,,548.68,,,per diem,,,51.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,51.31,,,percent of total billed charges,,,43.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.25,,,percent of total billed charges,,,51.31,,,percent of total billed charges,,,51.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.61,,,percent of total billed charges,,,41.52,,,percent of total billed charges,,,,,,,,,,,,,,,20.52,,,percent of total billed charges,,,,,,,,,18.98,,,percent of total billed charges,,,18.98,,,percent of total billed charges,,,,,,,,,51.31,,,percent of total billed charges,,,51.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,51.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.1,,,percent of total billed charges,,,51.31,,,percent of total billed charges,,,,,,,,,,,,,,,51.31,,,percent of total billed charges,,,51.31,,,percent of total billed charges,,,,,,,,,47.73,,,percent of total billed charges,,,,,,,,,,,,,,,47.73,,,percent of total billed charges,,,47.73,,,percent of total billed charges,,,47.73,,,percent of total billed charges,,,38.48,,,percent of total billed charges,,,51.31,,,percent of total billed charges,,,51.31,,,percent of total billed charges,,,51.31,,,percent of total billed charges,,,,,,,,,35.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,30.23,,,percent of total billed charges,,
VORTIOXETINE 10MG TAB,2500031993,CDM,637,RC,6476472030,NDC,999,EAPG,,,,outpatient,facility,5,UN,51.31,51.31,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VILAZODONE 20MG TAB,2500031994,CDM,637,RC,6476475030,NDC,,,,,,inpatient,facility,20,UN,53.86,53.86,4.31,53.86,,,,,,,,,,,,,,53.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.86,,,percent of total billed charges,,,,,,,,,53.86,,,percent of total billed charges,,,27.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.32,,,percent of total billed charges,,,,,,,,,,,,,,,53.86,,,percent of total billed charges,,,45.78,,,percent of total billed charges,,,,,,,,,,,,,,,53.86,,,percent of total billed charges,,,28.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,53.86,,,percent of total billed charges,,,,,,,,,,,,,,,4.31,,,percent of total billed charges,,,53.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.73,,,percent of total billed charges,,
VILAZODONE 20MG TAB,2500031994,CDM,637,RC,6476475030,NDC,,,,,,outpatient,facility,20,UN,53.86,53.86,4.31,548.68,,38.19,,,percent of total billed charges,,,13.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,53.86,,,percent of total billed charges,,,33.75,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,37.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,37.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,53.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,19.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,53.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,53.86,,,fee schedule,,,53.86,,,percent of total billed charges,,,,,,,,,53.86,,,percent of total billed charges,,,33.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.38,,,percent of total billed charges,,,,,,,,,,,,,,,29.08,,,percent of total billed charges,,,28.01,,,percent of total billed charges,,,29.62,,,percent of total billed charges,,,,,,,,,31.78,,,percent of total billed charges,,,548.68,,,per diem,,,53.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,53.86,,,percent of total billed charges,,,45.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.61,,,percent of total billed charges,,,53.86,,,percent of total billed charges,,,53.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.33,,,percent of total billed charges,,,43.58,,,percent of total billed charges,,,,,,,,,,,,,,,21.54,,,percent of total billed charges,,,,,,,,,19.93,,,percent of total billed charges,,,19.93,,,percent of total billed charges,,,,,,,,,53.86,,,percent of total billed charges,,,53.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,53.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.31,,,percent of total billed charges,,,53.86,,,percent of total billed charges,,,,,,,,,,,,,,,53.86,,,percent of total billed charges,,,53.86,,,percent of total billed charges,,,,,,,,,50.1,,,percent of total billed charges,,,,,,,,,,,,,,,50.1,,,percent of total billed charges,,,50.1,,,percent of total billed charges,,,50.1,,,percent of total billed charges,,,40.39,,,percent of total billed charges,,,53.86,,,percent of total billed charges,,,53.86,,,percent of total billed charges,,,53.86,,,percent of total billed charges,,,,,,,,,37.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,31.73,,,percent of total billed charges,,
VILAZODONE 20MG TAB,2500031994,CDM,637,RC,6476475030,NDC,999,EAPG,,,,outpatient,facility,20,UN,53.86,53.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SP-VEDOLIZUMAB 300 MG VIAL,2500031996,CDM,636,RC,J3380,HCPCS,6476430020,NDC,,,,inpatient,facility,300,UN,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-VEDOLIZUMAB 300 MG VIAL,2500031996,CDM,636,RC,J3380,HCPCS,6476430020,NDC,,,,outpatient,facility,300,UN,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,29.7,,,fee schedule,,,28.1,,,fee schedule,,,,,,,,,28.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-VEDOLIZUMAB 300 MG VIAL,2500031996,CDM,636,RC,J3380,HCPCS,6476430020,NDC,1489,APC,,outpatient,facility,300,UN,0.01,0.01,20.8,32.5,,,,,,,,22.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,21.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.67,,,fee schedule,,,,,,,,,,,,,,,22.75,,,fee schedule,,,22.75,,,fee schedule,,,,,,,,,21.67,,,fee schedule,,,21.67,,,fee schedule,,,22.75,,,fee schedule,,,,,,,,,,,,,,,32.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,21.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.8,,,fee schedule,,,23.19,,,fee schedule,,,22.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.67,,,fee schedule,,,21.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,22.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,21.67,,,fee schedule,,,,,,,,,27.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,21.67,,,fee schedule,,,21.67,,,fee schedule,,,,,,,,,,,,,,,21.67,,,fee schedule,,,,,,,,,21.67,,,fee schedule,,,22.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.67,,,fee schedule,,,,,,,,,,,,,,,22.54,,,fee schedule,,,21.67,,,fee schedule,,,,,,,,,21.67,,,fee schedule,,,,,,,,,21.67,,,fee schedule,,,22.75,,,fee schedule,,,,,,,,
SP-VEDOLIZUMAB 300 MG VIAL,2500031996,CDM,636,RC,J3380,HCPCS,6476430020,NDC,463,EAPG,,outpatient,facility,300,UN,0.01,0.01,7053.67,10651.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10651.04,,,fee schedule,,,7053.67,,,fee schedule,,,9468.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ORPHENADRINE 60 MG INJ,2500032000,CDM,636,RC,J2360,HCPCS,641618210,NDC,,,,inpatient,facility,2,UN,51.48,51.48,4.12,51.48,,,,,,,,,,,,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.48,,,percent of total billed charges,,,,,,,,,51.48,,,percent of total billed charges,,,26.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.89,,,percent of total billed charges,,,,,,,,,,,,,,,51.48,,,percent of total billed charges,,,43.76,,,percent of total billed charges,,,,,,,,,,,,,,,51.48,,,percent of total billed charges,,,27.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.33,,,percent of total billed charges,,
ORPHENADRINE 60 MG INJ,2500032000,CDM,636,RC,J2360,HCPCS,641618210,NDC,,,,outpatient,facility,2,UN,51.48,51.48,4.12,548.68,,36.5,,,percent of total billed charges,,,12.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,51.48,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,18.84,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,51.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,51.48,,,fee schedule,,,51.48,,,percent of total billed charges,,,,,,,,,51.48,,,percent of total billed charges,,,31.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,30.37,,,percent of total billed charges,,,548.68,,,per diem,,,51.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,51.48,,,percent of total billed charges,,,43.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.34,,,percent of total billed charges,,,51.48,,,percent of total billed charges,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.73,,,percent of total billed charges,,,41.66,,,percent of total billed charges,,,,,,,,,,,,,,,20.59,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,51.48,,,percent of total billed charges,,,51.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,51.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.12,,,percent of total billed charges,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,,51.48,,,percent of total billed charges,,,51.48,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,9.44,,,fee schedule,,,51.48,,,percent of total billed charges,,,51.48,,,percent of total billed charges,,,51.48,,,percent of total billed charges,,,,,,,,,36.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,30.33,,,percent of total billed charges,,
ORPHENADRINE 60 MG INJ,2500032000,CDM,636,RC,J2360,HCPCS,641618210,NDC,999,EAPG,,outpatient,facility,2,UN,51.48,51.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OSELTAMIVIR 6 MG/1 ML ORAL,2500032003,CDM,637,RC,4778138426,NDC,,,,,,inpatient,facility,1,UN,9.01,9.01,0.72,9.01,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,,,,,,,9.01,,,percent of total billed charges,,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.41,,,percent of total billed charges,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,4.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,
OSELTAMIVIR 6 MG/1 ML ORAL,2500032003,CDM,637,RC,4778138426,NDC,,,,,,outpatient,facility,1,UN,9.01,9.01,0.72,548.68,,6.39,,,percent of total billed charges,,,2.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.01,,,percent of total billed charges,,,5.65,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,6.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,6.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.3,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.01,,,fee schedule,,,9.01,,,percent of total billed charges,,,,,,,,,9.01,,,percent of total billed charges,,,5.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.42,,,percent of total billed charges,,,,,,,,,,,,,,,4.87,,,percent of total billed charges,,,4.69,,,percent of total billed charges,,,4.96,,,percent of total billed charges,,,,,,,,,5.32,,,percent of total billed charges,,,548.68,,,per diem,,,9.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.01,,,percent of total billed charges,,,7.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.79,,,percent of total billed charges,,,9.01,,,percent of total billed charges,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.08,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,,,,,,,,,,,,,3.6,,,percent of total billed charges,,,,,,,,,3.33,,,percent of total billed charges,,,3.33,,,percent of total billed charges,,,,,,,,,9.01,,,percent of total billed charges,,,9.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.72,,,percent of total billed charges,,,9.01,,,percent of total billed charges,,,,,,,,,,,,,,,9.01,,,percent of total billed charges,,,9.01,,,percent of total billed charges,,,,,,,,,8.38,,,percent of total billed charges,,,,,,,,,,,,,,,8.38,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,8.38,,,percent of total billed charges,,,6.76,,,percent of total billed charges,,,9.01,,,percent of total billed charges,,,9.01,,,percent of total billed charges,,,9.01,,,percent of total billed charges,,,,,,,,,6.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.31,,,percent of total billed charges,,
OSELTAMIVIR 6 MG/1 ML ORAL,2500032003,CDM,637,RC,4778138426,NDC,999,EAPG,,,,outpatient,facility,1,UN,9.01,9.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEXAMETHASONE 10 MG ORAL,2500032005,CDM,637,RC,J8540,HCPCS,6332350601,NDC,,,,inpatient,facility,1,UN,24.75,24.75,1.98,24.75,,,,,,,,,,,,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.75,,,percent of total billed charges,,,,,,,,,24.75,,,percent of total billed charges,,,12.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,,percent of total billed charges,,,,,,,,,,,,,,,24.75,,,percent of total billed charges,,,21.04,,,percent of total billed charges,,,,,,,,,,,,,,,24.75,,,percent of total billed charges,,,13.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,,1.98,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.58,,,percent of total billed charges,,
DEXAMETHASONE 10 MG ORAL,2500032005,CDM,637,RC,J8540,HCPCS,6332350601,NDC,,,,outpatient,facility,1,UN,24.75,24.75,0.07,548.68,,0.07,,,fee schedule,,,6.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,24.75,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.06,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,24.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,24.75,,,fee schedule,,,24.75,,,percent of total billed charges,,,,,,,,,24.75,,,percent of total billed charges,,,15.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,14.6,,,percent of total billed charges,,,548.68,,,per diem,,,24.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,24.75,,,percent of total billed charges,,,21.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.14,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.7,,,percent of total billed charges,,,20.03,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,24.75,,,percent of total billed charges,,,24.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.98,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,,24.75,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.07,,,fee schedule,,,24.75,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,24.75,,,percent of total billed charges,,,,,,,,,17.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14.58,,,percent of total billed charges,,
DEXAMETHASONE 10 MG ORAL,2500032005,CDM,637,RC,J8540,HCPCS,6332350601,NDC,999,EAPG,,outpatient,facility,1,UN,24.75,24.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
VEDOLIZUMAB 300 MG VIAL,2500032011,CDM,636,RC,J3380,HCPCS,6476430020,NDC,,,,inpatient,facility,300,UN,28599.71,28599.71,2287.98,28599.71,,,,,,,,,,,,,,28599.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28599.71,,,percent of total billed charges,,,,,,,,,28599.71,,,percent of total billed charges,,,14603.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24358.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17159.83,,,percent of total billed charges,,,,,,,,,,,,,,,28599.71,,,percent of total billed charges,,,24309.75,,,percent of total billed charges,,,,,,,,,,,,,,,28599.71,,,percent of total billed charges,,,15189.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11439.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,28599.71,,,percent of total billed charges,,,,,,,,,,,,,,,2287.98,,,percent of total billed charges,,,28599.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28599.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16850.95,,,percent of total billed charges,,
VEDOLIZUMAB 300 MG VIAL,2500032011,CDM,636,RC,J3380,HCPCS,6476430020,NDC,,,,outpatient,facility,300,UN,28599.71,28599.71,15.22,28599.71,,20280.05,,,percent of total billed charges,,,,,,,,,28599.71,,,percent of total billed charges,,,29.7,,,fee schedule,,,28.1,,,fee schedule,,,,,,,,,28.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,28599.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,28599.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,28599.71,,,fee schedule,,,28599.71,,,percent of total billed charges,,,,,,,,,28599.71,,,percent of total billed charges,,,17528.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20377.29,,,percent of total billed charges,,,,,,,,,,,,,,,22.06,,,fee schedule,,,22.06,,,fee schedule,,,22.06,,,fee schedule,,,,,,,,,16873.83,,,percent of total billed charges,,,548.68,,,per diem,,,28599.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,28599.71,,,percent of total billed charges,,,24309.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15189.31,,,percent of total billed charges,,,28599.71,,,percent of total billed charges,,,28599.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19293.36,,,percent of total billed charges,,,23142.89,,,percent of total billed charges,,,,,,,,,,,,,,,11439.88,,,percent of total billed charges,,,,,,,,,54.79,,,fee schedule,,,39.43,,,fee schedule,,,,,,,,,28599.71,,,percent of total billed charges,,,,,,,,,,,,,,,2287.98,,,percent of total billed charges,,,28599.71,,,percent of total billed charges,,,,,,,,,,,,,,,28599.71,,,percent of total billed charges,,,28599.71,,,percent of total billed charges,,,,,,,,,23.42,,,fee schedule,,,,,,,,,,,,,,,20.3,,,fee schedule,,,27.06,,,fee schedule,,,15.22,,,fee schedule,,,23.74,,,fee schedule,,,28599.71,,,percent of total billed charges,,,28599.71,,,percent of total billed charges,,,28599.71,,,percent of total billed charges,,,,,,,,,20051.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14299.85,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,16850.95,,,percent of total billed charges,,
VEDOLIZUMAB 300 MG VIAL,2500032011,CDM,636,RC,J3380,HCPCS,6476430020,NDC,1489,APC,,outpatient,facility,300,UN,28599.71,28599.71,20.8,10467.49,,,,,,,,22.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,21.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.89,,,fee schedule,,,,,,,,,10467.49,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,21.67,,,fee schedule,,,,,,,,,,,,,,,22.75,,,fee schedule,,,22.75,,,fee schedule,,,,,,,,,21.67,,,fee schedule,,,21.67,,,fee schedule,,,22.75,,,fee schedule,,,,,,,,,,,,,,,32.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,21.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.8,,,fee schedule,,,23.19,,,fee schedule,,,22.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.67,,,fee schedule,,,21.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,22.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,21.67,,,fee schedule,,,,,,,,,27.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,27.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,21.67,,,fee schedule,,,21.67,,,fee schedule,,,,,,,,,,,,,,,21.67,,,fee schedule,,,,,,,,,21.67,,,fee schedule,,,22.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.67,,,fee schedule,,,,,,,,,,,,,,,22.54,,,fee schedule,,,21.67,,,fee schedule,,,,,,,,,21.67,,,fee schedule,,,,,,,,,21.67,,,fee schedule,,,22.75,,,fee schedule,,,,,,,,
VEDOLIZUMAB 300 MG VIAL,2500032011,CDM,636,RC,J3380,HCPCS,6476430020,NDC,463,EAPG,,outpatient,facility,300,UN,28599.71,28599.71,7053.67,10651.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10651.04,,,fee schedule,,,7053.67,,,fee schedule,,,9468.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEGFILGRASTIM INJ 6 MG KIT,2500032012,CDM,636,RC,J2506,HCPCS,5551319201,NDC,,,,inpatient,facility,0.6,ML,21179.37,21179.37,1694.35,21179.37,,,,,,,,,,,,,,21179.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21179.37,,,percent of total billed charges,,,,,,,,,21179.37,,,percent of total billed charges,,,10814.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18038.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12707.62,,,percent of total billed charges,,,,,,,,,,,,,,,21179.37,,,percent of total billed charges,,,18002.46,,,percent of total billed charges,,,,,,,,,,,,,,,21179.37,,,percent of total billed charges,,,11248.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8471.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,21179.37,,,percent of total billed charges,,,,,,,,,,,,,,,1694.35,,,percent of total billed charges,,,21179.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21179.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12478.88,,,percent of total billed charges,,
PEGFILGRASTIM INJ 6 MG KIT,2500032012,CDM,636,RC,J2506,HCPCS,5551319201,NDC,,,,outpatient,facility,0.6,ML,21179.37,21179.37,19.98,21179.37,,15018.29,,,percent of total billed charges,,,,,,,,,21179.37,,,percent of total billed charges,,,71.56,,,fee schedule,,,67.7,,,fee schedule,,,,,,,,,67.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,21179.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,21179.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,19.98,,,fee schedule,,,21179.37,,,percent of total billed charges,,,,,,,,,21179.37,,,percent of total billed charges,,,12980.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15090.3,,,percent of total billed charges,,,,,,,,,,,,,,,50.68,,,fee schedule,,,50.68,,,fee schedule,,,50.68,,,fee schedule,,,,,,,,,12495.83,,,percent of total billed charges,,,548.68,,,per diem,,,21179.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,21179.37,,,percent of total billed charges,,,18002.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11248.36,,,percent of total billed charges,,,21179.37,,,percent of total billed charges,,,21179.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14287.6,,,percent of total billed charges,,,17138.35,,,percent of total billed charges,,,,,,,,,,,,,,,8471.75,,,percent of total billed charges,,,,,,,,,322.87,,,fee schedule,,,232.33,,,fee schedule,,,,,,,,,21179.37,,,percent of total billed charges,,,,,,,,,,,,,,,1694.35,,,percent of total billed charges,,,21179.37,,,percent of total billed charges,,,,,,,,,,,,,,,21179.37,,,percent of total billed charges,,,21179.37,,,percent of total billed charges,,,,,,,,,137.98,,,fee schedule,,,,,,,,,,,,,,,119.59,,,fee schedule,,,159.45,,,fee schedule,,,89.69,,,fee schedule,,,57.21,,,fee schedule,,,21179.37,,,percent of total billed charges,,,21179.37,,,percent of total billed charges,,,21179.37,,,percent of total billed charges,,,,,,,,,14848.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10589.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,12478.88,,,percent of total billed charges,,
PEGFILGRASTIM INJ 6 MG KIT,2500032012,CDM,636,RC,J2506,HCPCS,5551319201,NDC,9436,APC,,outpatient,facility,0.6,ML,21179.37,21179.37,19.18,29.97,,,,,,,,20.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.18,,,fee schedule,,,,,,,,,22.6,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,,,,,,,20.98,,,fee schedule,,,20.98,,,fee schedule,,,,,,,,,19.98,,,fee schedule,,,19.98,,,fee schedule,,,20.98,,,fee schedule,,,,,,,,,,,,,,,29.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.18,,,fee schedule,,,21.38,,,fee schedule,,,20.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,19.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,20.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,24.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,24.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,19.98,,,fee schedule,,,19.98,,,fee schedule,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,19.98,,,fee schedule,,,20.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.98,,,fee schedule,,,,,,,,,19.66,,,fee schedule,,,20.78,,,fee schedule,,,19.98,,,fee schedule,,,19.66,,,fee schedule,,,19.98,,,fee schedule,,,,,,,,,19.98,,,fee schedule,,,20.98,,,fee schedule,,,,,,,,
PEGFILGRASTIM INJ 6 MG KIT,2500032012,CDM,636,RC,J2506,HCPCS,5551319201,NDC,461,EAPG,,outpatient,facility,0.6,ML,21179.37,21179.37,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIVOLUMAB 100MG/10ML VIAL,2500032013,CDM,636,RC,J9299,HCPCS,3377412,NDC,,,,inpatient,facility,10,ML,10497.6,10497.6,839.81,10497.6,,,,,,,,,,,,,,10497.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10497.6,,,percent of total billed charges,,,,,,,,,10497.6,,,percent of total billed charges,,,5360.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8940.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6298.56,,,percent of total billed charges,,,,,,,,,,,,,,,10497.6,,,percent of total billed charges,,,8922.96,,,percent of total billed charges,,,,,,,,,,,,,,,10497.6,,,percent of total billed charges,,,5575.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4199.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10497.6,,,percent of total billed charges,,,,,,,,,,,,,,,839.81,,,percent of total billed charges,,,10497.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10497.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6185.19,,,percent of total billed charges,,
NIVOLUMAB 100MG/10ML VIAL,2500032013,CDM,636,RC,J9299,HCPCS,3377412,NDC,,,,outpatient,facility,10,ML,10497.6,10497.6,20.17,10497.6,,31.09,,,fee schedule,,,,,,,,,10497.6,,,percent of total billed charges,,,41.02,,,fee schedule,,,38.8,,,fee schedule,,,,,,,,,38.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,10497.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10497.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10497.6,,,fee schedule,,,10497.6,,,percent of total billed charges,,,,,,,,,10497.6,,,percent of total billed charges,,,6433.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7479.54,,,percent of total billed charges,,,,,,,,,,,,,,,31.09,,,fee schedule,,,31.09,,,fee schedule,,,31.09,,,fee schedule,,,,,,,,,6193.58,,,percent of total billed charges,,,548.68,,,per diem,,,10497.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10497.6,,,percent of total billed charges,,,8922.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5575.28,,,percent of total billed charges,,,10497.6,,,percent of total billed charges,,,10497.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7081.68,,,percent of total billed charges,,,8494.66,,,percent of total billed charges,,,,,,,,,,,,,,,4199.04,,,percent of total billed charges,,,,,,,,,72.6,,,fee schedule,,,52.24,,,fee schedule,,,,,,,,,10497.6,,,percent of total billed charges,,,,,,,,,,,,,,,839.81,,,percent of total billed charges,,,10497.6,,,percent of total billed charges,,,,,,,,,,,,,,,10497.6,,,percent of total billed charges,,,10497.6,,,percent of total billed charges,,,,,,,,,31.03,,,fee schedule,,,,,,,,,,,,,,,26.9,,,fee schedule,,,35.86,,,fee schedule,,,20.17,,,fee schedule,,,32.79,,,fee schedule,,,10497.6,,,percent of total billed charges,,,10497.6,,,percent of total billed charges,,,10497.6,,,percent of total billed charges,,,,,,,,,7359.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5248.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6185.19,,,percent of total billed charges,,
NIVOLUMAB 100MG/10ML VIAL,2500032013,CDM,636,RC,J9299,HCPCS,3377412,NDC,9453,APC,,outpatient,facility,10,ML,10497.6,10497.6,31.01,3842.12,,,,,,,,33.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.62,,,fee schedule,,,,,,,,,3842.12,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,33.92,,,fee schedule,,,33.92,,,fee schedule,,,,,,,,,32.3,,,fee schedule,,,32.3,,,fee schedule,,,33.92,,,fee schedule,,,,,,,,,,,,,,,48.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.01,,,fee schedule,,,34.56,,,fee schedule,,,33.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,33.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,40.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,32.3,,,fee schedule,,,32.3,,,fee schedule,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,32.3,,,fee schedule,,,33.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,33.59,,,fee schedule,,,32.3,,,fee schedule,,,,,,,,,32.3,,,fee schedule,,,,,,,,,32.3,,,fee schedule,,,33.92,,,fee schedule,,,,,,,,
NIVOLUMAB 100MG/10ML VIAL,2500032013,CDM,636,RC,J9299,HCPCS,3377412,NDC,463,EAPG,,outpatient,facility,10,ML,10497.6,10497.6,32.3,48.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.77,,,fee schedule,,,32.3,,,fee schedule,,,43.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,32.3,,,fee schedule,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIVOLUMAB 40MG/4ML VIAL,2500032014,CDM,636,RC,J9299,HCPCS,3377211,NDC,,,,inpatient,facility,4,ML,4199.05,4199.05,335.92,4199.05,,,,,,,,,,,,,,4199.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4199.05,,,percent of total billed charges,,,,,,,,,4199.05,,,percent of total billed charges,,,2144.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3576.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2519.43,,,percent of total billed charges,,,,,,,,,,,,,,,4199.05,,,percent of total billed charges,,,3569.19,,,percent of total billed charges,,,,,,,,,,,,,,,4199.05,,,percent of total billed charges,,,2230.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1679.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4199.05,,,percent of total billed charges,,,,,,,,,,,,,,,335.92,,,percent of total billed charges,,,4199.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4199.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2474.08,,,percent of total billed charges,,
NIVOLUMAB 40MG/4ML VIAL,2500032014,CDM,636,RC,J9299,HCPCS,3377211,NDC,,,,outpatient,facility,4,ML,4199.05,4199.05,20.17,4199.05,,31.09,,,fee schedule,,,,,,,,,4199.05,,,percent of total billed charges,,,41.02,,,fee schedule,,,38.8,,,fee schedule,,,,,,,,,38.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4199.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,4199.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,4199.05,,,fee schedule,,,4199.05,,,percent of total billed charges,,,,,,,,,4199.05,,,percent of total billed charges,,,2573.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2991.82,,,percent of total billed charges,,,,,,,,,,,,,,,31.09,,,fee schedule,,,31.09,,,fee schedule,,,31.09,,,fee schedule,,,,,,,,,2477.44,,,percent of total billed charges,,,548.68,,,per diem,,,4199.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4199.05,,,percent of total billed charges,,,3569.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2230.12,,,percent of total billed charges,,,4199.05,,,percent of total billed charges,,,4199.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2832.68,,,percent of total billed charges,,,3397.87,,,percent of total billed charges,,,,,,,,,,,,,,,1679.62,,,percent of total billed charges,,,,,,,,,72.6,,,fee schedule,,,52.24,,,fee schedule,,,,,,,,,4199.05,,,percent of total billed charges,,,,,,,,,,,,,,,335.92,,,percent of total billed charges,,,4199.05,,,percent of total billed charges,,,,,,,,,,,,,,,4199.05,,,percent of total billed charges,,,4199.05,,,percent of total billed charges,,,,,,,,,31.03,,,fee schedule,,,,,,,,,,,,,,,26.9,,,fee schedule,,,35.86,,,fee schedule,,,20.17,,,fee schedule,,,32.79,,,fee schedule,,,4199.05,,,percent of total billed charges,,,4199.05,,,percent of total billed charges,,,4199.05,,,percent of total billed charges,,,,,,,,,2943.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2099.53,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2474.08,,,percent of total billed charges,,
NIVOLUMAB 40MG/4ML VIAL,2500032014,CDM,636,RC,J9299,HCPCS,3377211,NDC,9453,APC,,outpatient,facility,4,ML,4199.05,4199.05,31.01,1536.85,,,,,,,,33.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.62,,,fee schedule,,,,,,,,,1536.85,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,33.92,,,fee schedule,,,33.92,,,fee schedule,,,,,,,,,32.3,,,fee schedule,,,32.3,,,fee schedule,,,33.92,,,fee schedule,,,,,,,,,,,,,,,48.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.01,,,fee schedule,,,34.56,,,fee schedule,,,33.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,33.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,40.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,32.3,,,fee schedule,,,32.3,,,fee schedule,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,32.3,,,fee schedule,,,33.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,33.59,,,fee schedule,,,32.3,,,fee schedule,,,,,,,,,32.3,,,fee schedule,,,,,,,,,32.3,,,fee schedule,,,33.92,,,fee schedule,,,,,,,,
NIVOLUMAB 40MG/4ML VIAL,2500032014,CDM,636,RC,J9299,HCPCS,3377211,NDC,463,EAPG,,outpatient,facility,4,ML,4199.05,4199.05,32.3,48.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.77,,,fee schedule,,,32.3,,,fee schedule,,,43.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,32.3,,,fee schedule,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMOXICIL/CLAV 250 MG/5 ML,2500032025,CDM,637,RC,5965102601,NDC,,,,,,inpatient,facility,5,UN,14.25,14.25,1.14,14.25,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,,,,,,,14.25,,,percent of total billed charges,,,7.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.55,,,percent of total billed charges,,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,12.11,,,percent of total billed charges,,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,7.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,1.14,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.4,,,percent of total billed charges,,
AMOXICIL/CLAV 250 MG/5 ML,2500032025,CDM,637,RC,5965102601,NDC,,,,,,outpatient,facility,5,UN,14.25,14.25,1.14,548.68,,10.1,,,percent of total billed charges,,,3.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.25,,,percent of total billed charges,,,8.93,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.25,,,fee schedule,,,14.25,,,percent of total billed charges,,,,,,,,,14.25,,,percent of total billed charges,,,8.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.15,,,percent of total billed charges,,,,,,,,,,,,,,,7.7,,,percent of total billed charges,,,7.41,,,percent of total billed charges,,,7.84,,,percent of total billed charges,,,,,,,,,8.41,,,percent of total billed charges,,,548.68,,,per diem,,,14.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.25,,,percent of total billed charges,,,12.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.57,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.61,,,percent of total billed charges,,,11.53,,,percent of total billed charges,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,,,,,,,5.27,,,percent of total billed charges,,,5.27,,,percent of total billed charges,,,,,,,,,14.25,,,percent of total billed charges,,,14.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.14,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,13.26,,,percent of total billed charges,,,,,,,,,,,,,,,13.26,,,percent of total billed charges,,,13.26,,,percent of total billed charges,,,13.26,,,percent of total billed charges,,,10.69,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,9.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.4,,,percent of total billed charges,,
AMOXICIL/CLAV 250 MG/5 ML,2500032025,CDM,637,RC,5965102601,NDC,999,EAPG,,,,outpatient,facility,5,UN,14.25,14.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AZITHROMYCIN 200 MG/5 ML,2500032026,CDM,637,RC,4280615134,NDC,,,,,,inpatient,facility,5,UN,19.17,19.17,1.53,19.17,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,,,,,,,19.17,,,percent of total billed charges,,,9.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.5,,,percent of total billed charges,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,16.29,,,percent of total billed charges,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,10.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.29,,,percent of total billed charges,,
AZITHROMYCIN 200 MG/5 ML,2500032026,CDM,637,RC,4280615134,NDC,,,,,,outpatient,facility,5,UN,19.17,19.17,1.53,548.68,,13.59,,,percent of total billed charges,,,4.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,19.17,,,percent of total billed charges,,,12.01,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,13.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,13.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.02,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,19.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,19.17,,,fee schedule,,,19.17,,,percent of total billed charges,,,,,,,,,19.17,,,percent of total billed charges,,,11.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.66,,,percent of total billed charges,,,,,,,,,,,,,,,10.35,,,percent of total billed charges,,,9.97,,,percent of total billed charges,,,10.54,,,percent of total billed charges,,,,,,,,,11.31,,,percent of total billed charges,,,548.68,,,per diem,,,19.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,19.17,,,percent of total billed charges,,,16.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.18,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.93,,,percent of total billed charges,,,15.51,,,percent of total billed charges,,,,,,,,,,,,,,,7.67,,,percent of total billed charges,,,,,,,,,7.09,,,percent of total billed charges,,,7.09,,,percent of total billed charges,,,,,,,,,19.17,,,percent of total billed charges,,,19.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.53,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,,,,,,,17.83,,,percent of total billed charges,,,,,,,,,,,,,,,17.83,,,percent of total billed charges,,,17.83,,,percent of total billed charges,,,17.83,,,percent of total billed charges,,,14.38,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,,,,,,,13.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.29,,,percent of total billed charges,,
AZITHROMYCIN 200 MG/5 ML,2500032026,CDM,637,RC,4280615134,NDC,999,EAPG,,,,outpatient,facility,5,UN,19.17,19.17,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEPHALEXIN 250 MG/5 ML SYR,2500032028,CDM,637,RC,6787754588,NDC,,,,,,inpatient,facility,5,UN,3.76,3.76,0.3,3.76,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,
CEPHALEXIN 250 MG/5 ML SYR,2500032028,CDM,637,RC,6787754588,NDC,,,,,,outpatient,facility,5,UN,3.76,3.76,0.3,548.68,,2.67,,,percent of total billed charges,,,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.76,,,percent of total billed charges,,,2.36,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.64,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.38,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.76,,,fee schedule,,,3.76,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,1.96,,,percent of total billed charges,,,2.07,,,percent of total billed charges,,,,,,,,,2.22,,,percent of total billed charges,,,548.68,,,per diem,,,3.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.76,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,1.39,,,percent of total billed charges,,,1.39,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,2.82,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.22,,,percent of total billed charges,,
CEPHALEXIN 250 MG/5 ML SYR,2500032028,CDM,637,RC,6787754588,NDC,999,EAPG,,,,outpatient,facility,5,UN,3.76,3.76,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTAZIDIME/AVIBACTAM 2G/0.5G,2500032030,CDM,636,RC,J0714,HCPCS,456270010,NDC,,,,inpatient,facility,2.5,GR,1305.45,1305.45,104.44,1305.45,,,,,,,,,,,,,,1305.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1305.45,,,percent of total billed charges,,,,,,,,,1305.45,,,percent of total billed charges,,,666.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1111.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,783.27,,,percent of total billed charges,,,,,,,,,,,,,,,1305.45,,,percent of total billed charges,,,1109.63,,,percent of total billed charges,,,,,,,,,,,,,,,1305.45,,,percent of total billed charges,,,693.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1305.45,,,percent of total billed charges,,,,,,,,,,,,,,,104.44,,,percent of total billed charges,,,1305.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1305.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,769.17,,,percent of total billed charges,,
CEFTAZIDIME/AVIBACTAM 2G/0.5G,2500032030,CDM,636,RC,J0714,HCPCS,456270010,NDC,,,,outpatient,facility,2.5,GR,1305.45,1305.45,62.54,1305.45,,925.69,,,percent of total billed charges,,,,,,,,,1305.45,,,percent of total billed charges,,,130.06,,,fee schedule,,,123.05,,,fee schedule,,,,,,,,,123.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1305.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1305.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1305.45,,,fee schedule,,,1305.45,,,percent of total billed charges,,,,,,,,,1305.45,,,percent of total billed charges,,,800.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,930.13,,,percent of total billed charges,,,,,,,,,,,,,,,95.45,,,fee schedule,,,95.45,,,fee schedule,,,95.45,,,fee schedule,,,,,,,,,770.22,,,percent of total billed charges,,,548.68,,,per diem,,,1305.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1305.45,,,percent of total billed charges,,,1109.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,693.32,,,percent of total billed charges,,,1305.45,,,percent of total billed charges,,,1305.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,880.66,,,percent of total billed charges,,,1056.37,,,percent of total billed charges,,,,,,,,,,,,,,,522.18,,,percent of total billed charges,,,,,,,,,225.16,,,fee schedule,,,162.02,,,fee schedule,,,,,,,,,1305.45,,,percent of total billed charges,,,,,,,,,,,,,,,104.44,,,percent of total billed charges,,,1305.45,,,percent of total billed charges,,,,,,,,,,,,,,,1305.45,,,percent of total billed charges,,,1305.45,,,percent of total billed charges,,,,,,,,,96.22,,,fee schedule,,,,,,,,,,,,,,,83.4,,,fee schedule,,,111.2,,,fee schedule,,,62.54,,,fee schedule,,,103.98,,,fee schedule,,,1305.45,,,percent of total billed charges,,,1305.45,,,percent of total billed charges,,,1305.45,,,percent of total billed charges,,,,,,,,,915.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,652.73,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,769.17,,,percent of total billed charges,,
CEFTAZIDIME/AVIBACTAM 2G/0.5G,2500032030,CDM,636,RC,J0714,HCPCS,456270010,NDC,1825,APC,,outpatient,facility,2.5,GR,1305.45,1305.45,96.7,477.79,,,,,,,,103.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,100.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.74,,,fee schedule,,,,,,,,,477.79,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,100.73,,,fee schedule,,,,,,,,,,,,,,,105.77,,,fee schedule,,,105.77,,,fee schedule,,,,,,,,,100.73,,,fee schedule,,,100.73,,,fee schedule,,,105.77,,,fee schedule,,,,,,,,,,,,,,,151.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,100.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.7,,,fee schedule,,,107.78,,,fee schedule,,,105.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.73,,,fee schedule,,,100.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,104.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,100.73,,,fee schedule,,,,,,,,,125.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,125.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,100.73,,,fee schedule,,,100.73,,,fee schedule,,,,,,,,,,,,,,,100.73,,,fee schedule,,,,,,,,,100.73,,,fee schedule,,,103.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.73,,,fee schedule,,,,,,,,,,,,,,,104.76,,,fee schedule,,,100.73,,,fee schedule,,,,,,,,,100.73,,,fee schedule,,,,,,,,,100.73,,,fee schedule,,,105.77,,,fee schedule,,,,,,,,
CEFTAZIDIME/AVIBACTAM 2G/0.5G,2500032030,CDM,636,RC,J0714,HCPCS,456270010,NDC,438,EAPG,,outpatient,facility,2.5,GR,1305.45,1305.45,332.92,502.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,502.71,,,fee schedule,,,332.92,,,fee schedule,,,446.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NEOSTIGMINE 3 MG/3 ML SYR,2500032041,CDM,636,RC,J2710,HCPCS,7604538330,NDC,,,,inpatient,facility,3,ML,49.5,49.5,3.96,49.5,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,25.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.7,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,42.08,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,26.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.17,,,percent of total billed charges,,
NEOSTIGMINE 3 MG/3 ML SYR,2500032041,CDM,636,RC,J2710,HCPCS,7604538330,NDC,,,,outpatient,facility,3,ML,49.5,49.5,0.43,548.68,,35.1,,,percent of total billed charges,,,12.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,49.5,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,18.12,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,49.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,49.5,,,fee schedule,,,49.5,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,30.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,29.2,,,percent of total billed charges,,,548.68,,,per diem,,,49.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,49.5,,,percent of total billed charges,,,42.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.29,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.39,,,percent of total billed charges,,,40.06,,,percent of total billed charges,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,49.5,,,percent of total billed charges,,,49.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,49.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.96,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.43,,,fee schedule,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,49.5,,,percent of total billed charges,,,,,,,,,34.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,29.17,,,percent of total billed charges,,
NEOSTIGMINE 3 MG/3 ML SYR,2500032041,CDM,636,RC,J2710,HCPCS,7604538330,NDC,999,EAPG,,outpatient,facility,3,ML,49.5,49.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPINEPHRINE INJ 0.1 MG,2500032055,CDM,636,RC,J0171,HCPCS,5428810310,NDC,,,,inpatient,facility,0.1,ML,0.59,0.59,0.05,0.59,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,
EPINEPHRINE INJ 0.1 MG,2500032055,CDM,636,RC,J0171,HCPCS,5428810310,NDC,,,,outpatient,facility,0.1,ML,0.59,0.59,0.05,548.68,,0.42,,,percent of total billed charges,,,0.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.59,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.49,,,fee schedule,,,0.59,,,fee schedule,,,0.59,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,0.35,,,percent of total billed charges,,,548.68,,,per diem,,,0.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.59,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,0.59,,,percent of total billed charges,,,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.59,,,fee schedule,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.35,,,percent of total billed charges,,
EPINEPHRINE INJ 0.1 MG,2500032055,CDM,636,RC,J0171,HCPCS,5428810310,NDC,496,EAPG,,outpatient,facility,0.1,ML,0.59,0.59,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PACLITAXEL INJ 1 MG,2500032056,CDM,636,RC,J9267,HCPCS,703321601,NDC,,,,inpatient,facility,0.1667,UN,1.32,1.32,0.11,1.32,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,0.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.11,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,
PACLITAXEL INJ 1 MG,2500032056,CDM,636,RC,J9267,HCPCS,703321601,NDC,,,,outpatient,facility,0.1667,UN,1.32,1.32,0.1,548.68,,0.11,,,fee schedule,,,0.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.32,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.48,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.32,,,fee schedule,,,1.32,,,percent of total billed charges,,,,,,,,,1.32,,,percent of total billed charges,,,0.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,0.78,,,percent of total billed charges,,,548.68,,,per diem,,,1.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.32,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,,percent of total billed charges,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1.32,,,percent of total billed charges,,,1.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.11,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.1,,,fee schedule,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,1.32,,,percent of total billed charges,,,,,,,,,0.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.78,,,percent of total billed charges,,
PACLITAXEL INJ 1 MG,2500032056,CDM,636,RC,J9267,HCPCS,703321601,NDC,430,EAPG,,outpatient,facility,0.1667,UN,1.32,1.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SACUBTRL/VALSRTAN 49/51 MG TAB,2500032060,CDM,637,RC,78077720,NDC,,,,,,inpatient,facility,1,UN,37.85,37.85,3.03,37.85,,,,,,,,,,,,,,37.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.85,,,percent of total billed charges,,,,,,,,,37.85,,,percent of total billed charges,,,19.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.71,,,percent of total billed charges,,,,,,,,,,,,,,,37.85,,,percent of total billed charges,,,32.17,,,percent of total billed charges,,,,,,,,,,,,,,,37.85,,,percent of total billed charges,,,20.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,37.85,,,percent of total billed charges,,,,,,,,,,,,,,,3.03,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.3,,,percent of total billed charges,,
SACUBTRL/VALSRTAN 49/51 MG TAB,2500032060,CDM,637,RC,78077720,NDC,,,,,,outpatient,facility,1,UN,37.85,37.85,3.03,548.68,,26.84,,,percent of total billed charges,,,9.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,37.85,,,percent of total billed charges,,,23.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,26.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,26.61,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,37.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,13.85,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,37.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,37.85,,,fee schedule,,,37.85,,,percent of total billed charges,,,,,,,,,37.85,,,percent of total billed charges,,,23.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.97,,,percent of total billed charges,,,,,,,,,,,,,,,20.44,,,percent of total billed charges,,,19.68,,,percent of total billed charges,,,20.82,,,percent of total billed charges,,,,,,,,,22.33,,,percent of total billed charges,,,548.68,,,per diem,,,37.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,37.85,,,percent of total billed charges,,,32.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.1,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.53,,,percent of total billed charges,,,30.63,,,percent of total billed charges,,,,,,,,,,,,,,,15.14,,,percent of total billed charges,,,,,,,,,14,,,percent of total billed charges,,,14,,,percent of total billed charges,,,,,,,,,37.85,,,percent of total billed charges,,,37.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,37.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.03,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,,,,,,,,,,,,,37.85,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,,,,,,,35.21,,,percent of total billed charges,,,,,,,,,,,,,,,35.21,,,percent of total billed charges,,,35.21,,,percent of total billed charges,,,35.21,,,percent of total billed charges,,,28.39,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,37.85,,,percent of total billed charges,,,,,,,,,26.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,22.3,,,percent of total billed charges,,
SACUBTRL/VALSRTAN 49/51 MG TAB,2500032060,CDM,637,RC,78077720,NDC,999,EAPG,,,,outpatient,facility,1,UN,37.85,37.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SP-DENOSUMAB INJ 60 MG,2500032064,CDM,636,RC,J0897,HCPCS,5551371001,NDC,,,,inpatient,facility,1,UN,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-DENOSUMAB INJ 60 MG,2500032064,CDM,636,RC,J0897,HCPCS,5551371001,NDC,,,,outpatient,facility,1,UN,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,34.72,,,fee schedule,,,32.85,,,fee schedule,,,,,,,,,32.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
SP-DENOSUMAB INJ 60 MG,2500032064,CDM,636,RC,J0897,HCPCS,5551371001,NDC,9272,APC,,outpatient,facility,1,UN,0.01,0.01,26.55,41.49,,,,,,,,28.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.94,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,,,,,,,29.04,,,fee schedule,,,29.04,,,fee schedule,,,,,,,,,27.66,,,fee schedule,,,27.66,,,fee schedule,,,29.04,,,fee schedule,,,,,,,,,,,,,,,41.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.55,,,fee schedule,,,29.6,,,fee schedule,,,29.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,27.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,28.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,34.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,34.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,27.66,,,fee schedule,,,27.66,,,fee schedule,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,27.66,,,fee schedule,,,28.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.66,,,fee schedule,,,,,,,,,,,,,,,28.77,,,fee schedule,,,27.66,,,fee schedule,,,,,,,,,27.66,,,fee schedule,,,,,,,,,27.66,,,fee schedule,,,29.04,,,fee schedule,,,,,,,,
SP-DENOSUMAB INJ 60 MG,2500032064,CDM,636,RC,J0897,HCPCS,5551371001,NDC,443,EAPG,,outpatient,facility,1,UN,0.01,0.01,1101.65,1663.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1663.49,,,fee schedule,,,1101.65,,,fee schedule,,,1478.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1101.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1101.65,,,fee schedule,,,1101.65,,,fee schedule,,,1101.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1101.65,,,fee schedule,,,,,,,,,,,,,,,1101.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MNTHL SUGR FREE LZNGE 1 LOZ,2500032099,CDM,637,RC,3660219209,NDC,,,,,,inpatient,facility,1,UN,0.4,0.4,0.03,0.4,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,0.4,,,percent of total billed charges,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,
MNTHL SUGR FREE LZNGE 1 LOZ,2500032099,CDM,637,RC,3660219209,NDC,,,,,,outpatient,facility,1,UN,0.4,0.4,0.03,548.68,,0.28,,,percent of total billed charges,,,0.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.4,,,percent of total billed charges,,,0.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.15,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.4,,,fee schedule,,,0.4,,,percent of total billed charges,,,,,,,,,0.4,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,,,,,,,,,,,,,,0.22,,,percent of total billed charges,,,0.21,,,percent of total billed charges,,,0.22,,,percent of total billed charges,,,,,,,,,0.24,,,percent of total billed charges,,,548.68,,,per diem,,,0.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.4,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.21,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,,,,,,,0.15,,,percent of total billed charges,,,0.15,,,percent of total billed charges,,,,,,,,,0.4,,,percent of total billed charges,,,0.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.03,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,0.3,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.24,,,percent of total billed charges,,
MNTHL SUGR FREE LZNGE 1 LOZ,2500032099,CDM,637,RC,3660219209,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.4,0.4,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEMBROLIZUMAB 100 MG/4 ML VIAL,2500032100,CDM,636,RC,J9271,HCPCS,6302604,NDC,,,,inpatient,facility,4,ML,18706.64,18706.64,1496.53,18706.64,,,,,,,,,,,,,,18706.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18706.64,,,percent of total billed charges,,,,,,,,,18706.64,,,percent of total billed charges,,,9551.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15932.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11223.98,,,percent of total billed charges,,,,,,,,,,,,,,,18706.64,,,percent of total billed charges,,,15900.64,,,percent of total billed charges,,,,,,,,,,,,,,,18706.64,,,percent of total billed charges,,,9935.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7482.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,18706.64,,,percent of total billed charges,,,,,,,,,,,,,,,1496.53,,,percent of total billed charges,,,18706.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18706.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11021.95,,,percent of total billed charges,,
PEMBROLIZUMAB 100 MG/4 ML VIAL,2500032100,CDM,636,RC,J9271,HCPCS,6302604,NDC,,,,outpatient,facility,4,ML,18706.64,18706.64,37.23,18706.64,,57.31,,,fee schedule,,,,,,,,,18706.64,,,percent of total billed charges,,,73.54,,,fee schedule,,,69.58,,,fee schedule,,,,,,,,,69.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,18706.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,18706.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,18706.64,,,fee schedule,,,18706.64,,,percent of total billed charges,,,,,,,,,18706.64,,,percent of total billed charges,,,11465.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13328.48,,,percent of total billed charges,,,,,,,,,,,,,,,55.73,,,fee schedule,,,55.73,,,fee schedule,,,55.73,,,fee schedule,,,,,,,,,11036.92,,,percent of total billed charges,,,548.68,,,per diem,,,18706.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,18706.64,,,percent of total billed charges,,,15900.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9935.1,,,percent of total billed charges,,,18706.64,,,percent of total billed charges,,,18706.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12619.5,,,percent of total billed charges,,,15137.41,,,percent of total billed charges,,,,,,,,,,,,,,,7482.66,,,percent of total billed charges,,,,,,,,,134.03,,,fee schedule,,,96.44,,,fee schedule,,,,,,,,,18706.64,,,percent of total billed charges,,,,,,,,,,,,,,,1496.53,,,percent of total billed charges,,,18706.64,,,percent of total billed charges,,,,,,,,,,,,,,,18706.64,,,percent of total billed charges,,,18706.64,,,percent of total billed charges,,,,,,,,,57.28,,,fee schedule,,,,,,,,,,,,,,,49.64,,,fee schedule,,,66.19,,,fee schedule,,,37.23,,,fee schedule,,,58.8,,,fee schedule,,,18706.64,,,percent of total billed charges,,,18706.64,,,percent of total billed charges,,,18706.64,,,percent of total billed charges,,,,,,,,,13115.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9353.32,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11021.95,,,percent of total billed charges,,
PEMBROLIZUMAB 100 MG/4 ML VIAL,2500032100,CDM,636,RC,J9271,HCPCS,6302604,NDC,1490,APC,,outpatient,facility,4,ML,18706.64,18706.64,55.3,6846.63,,,,,,,,59.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,57.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.18,,,fee schedule,,,,,,,,,6846.63,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,57.6,,,fee schedule,,,,,,,,,,,,,,,60.48,,,fee schedule,,,60.48,,,fee schedule,,,,,,,,,57.6,,,fee schedule,,,57.6,,,fee schedule,,,60.48,,,fee schedule,,,,,,,,,,,,,,,86.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,57.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.3,,,fee schedule,,,61.63,,,fee schedule,,,60.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.6,,,fee schedule,,,57.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,59.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,57.6,,,fee schedule,,,,,,,,,72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,57.6,,,fee schedule,,,57.6,,,fee schedule,,,,,,,,,,,,,,,57.6,,,fee schedule,,,,,,,,,57.6,,,fee schedule,,,59.33,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.6,,,fee schedule,,,,,,,,,,,,,,,59.9,,,fee schedule,,,57.6,,,fee schedule,,,,,,,,,57.6,,,fee schedule,,,,,,,,,57.6,,,fee schedule,,,60.48,,,fee schedule,,,,,,,,
PEMBROLIZUMAB 100 MG/4 ML VIAL,2500032100,CDM,636,RC,J9271,HCPCS,6302604,NDC,464,EAPG,,outpatient,facility,4,ML,18706.64,18706.64,57.6,86.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.98,,,fee schedule,,,57.6,,,fee schedule,,,77.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.6,,,fee schedule,,,57.6,,,fee schedule,,,57.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,57.6,,,fee schedule,,,,,,,,,,,,,,,57.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FILGRASTIM-SNDZ 300 MCG SYR,2500032112,CDM,636,RC,Q5101,HCPCS,5551392491,NDC,,,,inpatient,facility,0.5,UN,1101.21,1101.21,88.1,1101.21,,,,,,,,,,,,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1101.21,,,percent of total billed charges,,,,,,,,,1101.21,,,percent of total billed charges,,,562.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,937.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,660.73,,,percent of total billed charges,,,,,,,,,,,,,,,1101.21,,,percent of total billed charges,,,936.03,,,percent of total billed charges,,,,,,,,,,,,,,,1101.21,,,percent of total billed charges,,,584.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,440.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,,88.1,,,percent of total billed charges,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,648.83,,,percent of total billed charges,,
FILGRASTIM-SNDZ 300 MCG SYR,2500032112,CDM,636,RC,Q5101,HCPCS,5551392491,NDC,,,,outpatient,facility,0.5,UN,1101.21,1101.21,0.25,1101.21,,780.87,,,percent of total billed charges,,,,,,,,,1101.21,,,percent of total billed charges,,,0.32,,,fee schedule,,,0.31,,,fee schedule,,,,,,,,,0.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1101.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1101.21,,,fee schedule,,,1101.21,,,percent of total billed charges,,,,,,,,,1101.21,,,percent of total billed charges,,,674.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,784.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.32,,,fee schedule,,,0.32,,,fee schedule,,,0.32,,,fee schedule,,,,,,,,,649.71,,,percent of total billed charges,,,548.68,,,per diem,,,1101.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1101.21,,,percent of total billed charges,,,936.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,584.85,,,percent of total billed charges,,,1101.21,,,percent of total billed charges,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.88,,,percent of total billed charges,,,891.1,,,percent of total billed charges,,,,,,,,,,,,,,,440.48,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,,88.1,,,percent of total billed charges,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,,1101.21,,,percent of total billed charges,,,1101.21,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.25,,,fee schedule,,,1101.21,,,percent of total billed charges,,,1101.21,,,percent of total billed charges,,,1101.21,,,percent of total billed charges,,,,,,,,,772.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,550.61,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,648.83,,,percent of total billed charges,,
FILGRASTIM-SNDZ 300 MCG SYR,2500032112,CDM,636,RC,Q5101,HCPCS,5551392491,NDC,1822,APC,,outpatient,facility,0.5,UN,1101.21,1101.21,0.35,403.04,,,,,,,,0.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,fee schedule,,,,,,,,,403.04,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,fee schedule,,,,,,,,,,,,,,,0.38,,,fee schedule,,,0.38,,,fee schedule,,,,,,,,,0.36,,,fee schedule,,,0.36,,,fee schedule,,,0.38,,,fee schedule,,,,,,,,,,,,,,,0.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.35,,,fee schedule,,,0.39,,,fee schedule,,,0.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,fee schedule,,,0.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,fee schedule,,,,,,,,,0.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.36,,,fee schedule,,,0.36,,,fee schedule,,,,,,,,,,,,,,,0.36,,,fee schedule,,,,,,,,,0.36,,,fee schedule,,,0.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,fee schedule,,,,,,,,,,,,,,,0.37,,,fee schedule,,,0.36,,,fee schedule,,,,,,,,,0.36,,,fee schedule,,,,,,,,,0.36,,,fee schedule,,,0.38,,,fee schedule,,,,,,,,
FILGRASTIM-SNDZ 300 MCG SYR,2500032112,CDM,636,RC,Q5101,HCPCS,5551392491,NDC,437,EAPG,,outpatient,facility,0.5,UN,1101.21,1101.21,156.28,235.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.98,,,fee schedule,,,156.28,,,fee schedule,,,209.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INSULIN R U-500 1500 UNIT/3 ML,2500032115,CDM,637,RC,J1815,HCPCS,2882427,NDC,,,,inpatient,facility,3,UN,947.43,947.43,75.79,947.43,,,,,,,,,,,,,,947.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,947.43,,,percent of total billed charges,,,,,,,,,947.43,,,percent of total billed charges,,,483.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,806.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,568.46,,,percent of total billed charges,,,,,,,,,,,,,,,947.43,,,percent of total billed charges,,,805.32,,,percent of total billed charges,,,,,,,,,,,,,,,947.43,,,percent of total billed charges,,,503.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,378.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,947.43,,,percent of total billed charges,,,,,,,,,,,,,,,75.79,,,percent of total billed charges,,,947.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,947.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,558.23,,,percent of total billed charges,,
INSULIN R U-500 1500 UNIT/3 ML,2500032115,CDM,637,RC,J1815,HCPCS,2882427,NDC,,,,outpatient,facility,3,UN,947.43,947.43,0.94,947.43,,671.82,,,percent of total billed charges,,,231.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,947.43,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,947.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,346.76,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,947.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,947.43,,,fee schedule,,,947.43,,,percent of total billed charges,,,,,,,,,947.43,,,percent of total billed charges,,,580.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,675.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,558.98,,,percent of total billed charges,,,548.68,,,per diem,,,947.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,947.43,,,percent of total billed charges,,,805.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,503.18,,,percent of total billed charges,,,947.43,,,percent of total billed charges,,,947.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,639.14,,,percent of total billed charges,,,766.66,,,percent of total billed charges,,,,,,,,,,,,,,,378.97,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,947.43,,,percent of total billed charges,,,947.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,947.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,75.79,,,percent of total billed charges,,,947.43,,,percent of total billed charges,,,,,,,,,,,,,,,947.43,,,percent of total billed charges,,,947.43,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.94,,,fee schedule,,,947.43,,,percent of total billed charges,,,947.43,,,percent of total billed charges,,,947.43,,,percent of total billed charges,,,,,,,,,664.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.71,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,558.23,,,percent of total billed charges,,
INSULIN R U-500 1500 UNIT/3 ML,2500032115,CDM,637,RC,J1815,HCPCS,2882427,NDC,496,EAPG,,outpatient,facility,3,UN,947.43,947.43,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ATEZOLIZUMAB 1200 MG VIAL,2500032134,CDM,636,RC,J9022,HCPCS,5024291701,NDC,,,,inpatient,facility,20,ML,36049.49,36049.49,2883.96,36049.49,,,,,,,,,,,,,,36049.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36049.49,,,percent of total billed charges,,,,,,,,,36049.49,,,percent of total billed charges,,,18406.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30703.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21629.69,,,percent of total billed charges,,,,,,,,,,,,,,,36049.49,,,percent of total billed charges,,,30642.07,,,percent of total billed charges,,,,,,,,,,,,,,,36049.49,,,percent of total billed charges,,,19145.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14419.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,36049.49,,,percent of total billed charges,,,,,,,,,,,,,,,2883.96,,,percent of total billed charges,,,36049.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36049.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21240.36,,,percent of total billed charges,,
ATEZOLIZUMAB 1200 MG VIAL,2500032134,CDM,636,RC,J9022,HCPCS,5024291701,NDC,,,,outpatient,facility,20,ML,36049.49,36049.49,56.01,36049.49,,83.94,,,fee schedule,,,,,,,,,36049.49,,,percent of total billed charges,,,111.34,,,fee schedule,,,105.34,,,fee schedule,,,,,,,,,105.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,36049.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,36049.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,36049.49,,,fee schedule,,,36049.49,,,percent of total billed charges,,,,,,,,,36049.49,,,percent of total billed charges,,,22094.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25685.26,,,percent of total billed charges,,,,,,,,,,,,,,,85.01,,,fee schedule,,,85.01,,,fee schedule,,,85.01,,,fee schedule,,,,,,,,,21269.2,,,percent of total billed charges,,,548.68,,,per diem,,,36049.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,36049.49,,,percent of total billed charges,,,30642.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19145.88,,,percent of total billed charges,,,36049.49,,,percent of total billed charges,,,36049.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24318.99,,,percent of total billed charges,,,29171.25,,,percent of total billed charges,,,,,,,,,,,,,,,14419.8,,,percent of total billed charges,,,,,,,,,201.65,,,fee schedule,,,145.1,,,fee schedule,,,,,,,,,36049.49,,,percent of total billed charges,,,,,,,,,,,,,,,2883.96,,,percent of total billed charges,,,36049.49,,,percent of total billed charges,,,,,,,,,,,,,,,36049.49,,,percent of total billed charges,,,36049.49,,,percent of total billed charges,,,,,,,,,86.17,,,fee schedule,,,,,,,,,,,,,,,74.69,,,fee schedule,,,99.58,,,fee schedule,,,56.01,,,fee schedule,,,89.01,,,fee schedule,,,36049.49,,,percent of total billed charges,,,36049.49,,,percent of total billed charges,,,36049.49,,,percent of total billed charges,,,,,,,,,25274.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18024.74,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,21240.36,,,percent of total billed charges,,
ATEZOLIZUMAB 1200 MG VIAL,2500032134,CDM,636,RC,J9022,HCPCS,5024291701,NDC,9483,APC,,outpatient,facility,20,ML,36049.49,36049.49,84.69,13194.11,,,,,,,,90.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.1,,,fee schedule,,,,,,,,,13194.11,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,,,,,,,92.63,,,fee schedule,,,92.63,,,fee schedule,,,,,,,,,88.22,,,fee schedule,,,88.22,,,fee schedule,,,92.63,,,fee schedule,,,,,,,,,,,,,,,132.33,,,fee schedule,,,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.69,,,fee schedule,,,94.4,,,fee schedule,,,92.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,88.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,91.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,110.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,110.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,88.22,,,fee schedule,,,88.22,,,fee schedule,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,88.22,,,fee schedule,,,90.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,,,,,,,91.75,,,fee schedule,,,88.22,,,fee schedule,,,,,,,,,88.22,,,fee schedule,,,,,,,,,88.22,,,fee schedule,,,92.63,,,fee schedule,,,,,,,,
ATEZOLIZUMAB 1200 MG VIAL,2500032134,CDM,636,RC,J9022,HCPCS,5024291701,NDC,464,EAPG,,outpatient,facility,20,ML,36049.49,36049.49,88.22,133.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.21,,,fee schedule,,,88.22,,,fee schedule,,,118.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,88.22,,,fee schedule,,,88.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,,,,,,,88.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LINACLOTIDE 145 MCG CAP,2500032143,CDM,637,RC,456120130,NDC,,,,,,inpatient,facility,145,UN,59.5,59.5,4.76,59.5,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,,,,,,,,59.5,,,percent of total billed charges,,,30.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.7,,,percent of total billed charges,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,,50.58,,,percent of total billed charges,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,,31.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,4.76,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.06,,,percent of total billed charges,,
LINACLOTIDE 145 MCG CAP,2500032143,CDM,637,RC,456120130,NDC,,,,,,outpatient,facility,145,UN,59.5,59.5,4.76,548.68,,42.19,,,percent of total billed charges,,,14.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,59.5,,,percent of total billed charges,,,37.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,41.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,41.83,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,21.78,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,59.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,59.5,,,fee schedule,,,59.5,,,percent of total billed charges,,,,,,,,,59.5,,,percent of total billed charges,,,36.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.39,,,percent of total billed charges,,,,,,,,,,,,,,,32.13,,,percent of total billed charges,,,30.94,,,percent of total billed charges,,,32.73,,,percent of total billed charges,,,,,,,,,35.1,,,percent of total billed charges,,,548.68,,,per diem,,,59.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,59.5,,,percent of total billed charges,,,50.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.6,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.14,,,percent of total billed charges,,,48.15,,,percent of total billed charges,,,,,,,,,,,,,,,23.8,,,percent of total billed charges,,,,,,,,,22.02,,,percent of total billed charges,,,22.02,,,percent of total billed charges,,,,,,,,,59.5,,,percent of total billed charges,,,59.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,59.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.76,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,,,,,,,55.35,,,percent of total billed charges,,,,,,,,,,,,,,,55.35,,,percent of total billed charges,,,55.35,,,percent of total billed charges,,,55.35,,,percent of total billed charges,,,44.63,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,,,,,,,41.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,35.06,,,percent of total billed charges,,
LINACLOTIDE 145 MCG CAP,2500032143,CDM,637,RC,456120130,NDC,999,EAPG,,,,outpatient,facility,145,UN,59.5,59.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CHOLECALCFERL 50000UNIT CAPSLE,2500032151,CDM,637,RC,7583402001,NDC,,,,,,inpatient,facility,50000,UN,0.84,0.84,0.07,0.84,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,0.84,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.07,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,
CHOLECALCFERL 50000UNIT CAPSLE,2500032151,CDM,637,RC,7583402001,NDC,,,,,,outpatient,facility,50000,UN,0.84,0.84,0.07,548.68,,0.6,,,percent of total billed charges,,,0.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.84,,,percent of total billed charges,,,0.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.59,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.31,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.84,,,fee schedule,,,0.84,,,percent of total billed charges,,,,,,,,,0.84,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,0.44,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,0.5,,,percent of total billed charges,,,548.68,,,per diem,,,0.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.84,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.57,,,percent of total billed charges,,,0.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,,,,,,,0.31,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,0.84,,,percent of total billed charges,,,0.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.07,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,0.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,0.78,,,percent of total billed charges,,,0.63,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.49,,,percent of total billed charges,,
CHOLECALCFERL 50000UNIT CAPSLE,2500032151,CDM,637,RC,7583402001,NDC,999,EAPG,,,,outpatient,facility,50000,UN,0.84,0.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMOXICIL/CLAV 600MG/5ML,2500032155,CDM,637,RC,6586253513,NDC,,,,,,inpatient,facility,5,UN,10.96,10.96,0.88,10.96,,,,,,,,,,,,,,10.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.96,,,percent of total billed charges,,,,,,,,,10.96,,,percent of total billed charges,,,5.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.58,,,percent of total billed charges,,,,,,,,,,,,,,,10.96,,,percent of total billed charges,,,9.32,,,percent of total billed charges,,,,,,,,,,,,,,,10.96,,,percent of total billed charges,,,5.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,10.96,,,percent of total billed charges,,,,,,,,,,,,,,,0.88,,,percent of total billed charges,,,10.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.46,,,percent of total billed charges,,
AMOXICIL/CLAV 600MG/5ML,2500032155,CDM,637,RC,6586253513,NDC,,,,,,outpatient,facility,5,UN,10.96,10.96,0.88,548.68,,7.77,,,percent of total billed charges,,,2.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,10.96,,,percent of total billed charges,,,6.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,7.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,7.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,10.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,10.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,10.96,,,fee schedule,,,10.96,,,percent of total billed charges,,,,,,,,,10.96,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.81,,,percent of total billed charges,,,,,,,,,,,,,,,5.92,,,percent of total billed charges,,,5.7,,,percent of total billed charges,,,6.03,,,percent of total billed charges,,,,,,,,,6.47,,,percent of total billed charges,,,548.68,,,per diem,,,10.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,10.96,,,percent of total billed charges,,,9.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.82,,,percent of total billed charges,,,10.96,,,percent of total billed charges,,,10.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,8.87,,,percent of total billed charges,,,,,,,,,,,,,,,4.38,,,percent of total billed charges,,,,,,,,,4.06,,,percent of total billed charges,,,4.06,,,percent of total billed charges,,,,,,,,,10.96,,,percent of total billed charges,,,10.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.88,,,percent of total billed charges,,,10.96,,,percent of total billed charges,,,,,,,,,,,,,,,10.96,,,percent of total billed charges,,,10.96,,,percent of total billed charges,,,,,,,,,10.19,,,percent of total billed charges,,,,,,,,,,,,,,,10.19,,,percent of total billed charges,,,10.19,,,percent of total billed charges,,,10.19,,,percent of total billed charges,,,8.22,,,percent of total billed charges,,,10.96,,,percent of total billed charges,,,10.96,,,percent of total billed charges,,,10.96,,,percent of total billed charges,,,,,,,,,7.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.48,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.46,,,percent of total billed charges,,
AMOXICIL/CLAV 600MG/5ML,2500032155,CDM,637,RC,6586253513,NDC,999,EAPG,,,,outpatient,facility,5,UN,10.96,10.96,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFPODOXIME 100MG/5ML SYR,2500032159,CDM,637,RC,6586214150,NDC,,,,,,inpatient,facility,5,UN,28.44,28.44,2.28,28.44,,,,,,,,,,,,,,28.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.44,,,percent of total billed charges,,,,,,,,,28.44,,,percent of total billed charges,,,14.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.06,,,percent of total billed charges,,,,,,,,,,,,,,,28.44,,,percent of total billed charges,,,24.17,,,percent of total billed charges,,,,,,,,,,,,,,,28.44,,,percent of total billed charges,,,15.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,28.44,,,percent of total billed charges,,,,,,,,,,,,,,,2.28,,,percent of total billed charges,,,28.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.76,,,percent of total billed charges,,
CEFPODOXIME 100MG/5ML SYR,2500032159,CDM,637,RC,6586214150,NDC,,,,,,outpatient,facility,5,UN,28.44,28.44,2.28,548.68,,20.17,,,percent of total billed charges,,,6.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,28.44,,,percent of total billed charges,,,17.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,19.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,19.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,28.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,10.41,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,28.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,28.44,,,fee schedule,,,28.44,,,percent of total billed charges,,,,,,,,,28.44,,,percent of total billed charges,,,17.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.26,,,percent of total billed charges,,,,,,,,,,,,,,,15.36,,,percent of total billed charges,,,14.79,,,percent of total billed charges,,,15.64,,,percent of total billed charges,,,,,,,,,16.78,,,percent of total billed charges,,,548.68,,,per diem,,,28.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,28.44,,,percent of total billed charges,,,24.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.1,,,percent of total billed charges,,,28.44,,,percent of total billed charges,,,28.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.19,,,percent of total billed charges,,,23.01,,,percent of total billed charges,,,,,,,,,,,,,,,11.38,,,percent of total billed charges,,,,,,,,,10.52,,,percent of total billed charges,,,10.52,,,percent of total billed charges,,,,,,,,,28.44,,,percent of total billed charges,,,28.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,28.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.28,,,percent of total billed charges,,,28.44,,,percent of total billed charges,,,,,,,,,,,,,,,28.44,,,percent of total billed charges,,,28.44,,,percent of total billed charges,,,,,,,,,26.45,,,percent of total billed charges,,,,,,,,,,,,,,,26.45,,,percent of total billed charges,,,26.45,,,percent of total billed charges,,,26.45,,,percent of total billed charges,,,21.33,,,percent of total billed charges,,,28.44,,,percent of total billed charges,,,28.44,,,percent of total billed charges,,,28.44,,,percent of total billed charges,,,,,,,,,19.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,16.76,,,percent of total billed charges,,
CEFPODOXIME 100MG/5ML SYR,2500032159,CDM,637,RC,6586214150,NDC,999,EAPG,,,,outpatient,facility,5,UN,28.44,28.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TETRACAINE 0.5  OPH 4 ML,2500032162,CDM,637,RC,65074114,NDC,,,,,,inpatient,facility,4,UN,43.63,43.63,3.49,43.63,,,,,,,,,,,,,,43.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.63,,,percent of total billed charges,,,,,,,,,43.63,,,percent of total billed charges,,,22.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.18,,,percent of total billed charges,,,,,,,,,,,,,,,43.63,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,43.63,,,percent of total billed charges,,,23.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,43.63,,,percent of total billed charges,,,,,,,,,,,,,,,3.49,,,percent of total billed charges,,,43.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.71,,,percent of total billed charges,,
TETRACAINE 0.5  OPH 4 ML,2500032162,CDM,637,RC,65074114,NDC,,,,,,outpatient,facility,4,UN,43.63,43.63,3.49,548.68,,30.94,,,percent of total billed charges,,,10.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,43.63,,,percent of total billed charges,,,27.34,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,30.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,30.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,43.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,15.97,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,43.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,43.63,,,fee schedule,,,43.63,,,percent of total billed charges,,,,,,,,,43.63,,,percent of total billed charges,,,26.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.09,,,percent of total billed charges,,,,,,,,,,,,,,,23.56,,,percent of total billed charges,,,22.69,,,percent of total billed charges,,,24,,,percent of total billed charges,,,,,,,,,25.74,,,percent of total billed charges,,,548.68,,,per diem,,,43.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,43.63,,,percent of total billed charges,,,37.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.17,,,percent of total billed charges,,,43.63,,,percent of total billed charges,,,43.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.43,,,percent of total billed charges,,,35.31,,,percent of total billed charges,,,,,,,,,,,,,,,17.45,,,percent of total billed charges,,,,,,,,,16.14,,,percent of total billed charges,,,16.14,,,percent of total billed charges,,,,,,,,,43.63,,,percent of total billed charges,,,43.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,43.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.49,,,percent of total billed charges,,,43.63,,,percent of total billed charges,,,,,,,,,,,,,,,43.63,,,percent of total billed charges,,,43.63,,,percent of total billed charges,,,,,,,,,40.58,,,percent of total billed charges,,,,,,,,,,,,,,,40.58,,,percent of total billed charges,,,40.58,,,percent of total billed charges,,,40.58,,,percent of total billed charges,,,32.72,,,percent of total billed charges,,,43.63,,,percent of total billed charges,,,43.63,,,percent of total billed charges,,,43.63,,,percent of total billed charges,,,,,,,,,30.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,25.71,,,percent of total billed charges,,
TETRACAINE 0.5  OPH 4 ML,2500032162,CDM,637,RC,65074114,NDC,999,EAPG,,,,outpatient,facility,4,UN,43.63,43.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ARGATROBAN 250MG INJ NON-ESRD,2500032165,CDM,636,RC,J0883,HCPCS,4202318201,NDC,,,,inpatient,facility,2.5,GR,1683,1683,134.64,1683,,,,,,,,,,,,,,1683,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1683,,,percent of total billed charges,,,,,,,,,1683,,,percent of total billed charges,,,859.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1433.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1009.8,,,percent of total billed charges,,,,,,,,,,,,,,,1683,,,percent of total billed charges,,,1430.55,,,percent of total billed charges,,,,,,,,,,,,,,,1683,,,percent of total billed charges,,,893.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,673.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1683,,,percent of total billed charges,,,,,,,,,,,,,,,134.64,,,percent of total billed charges,,,1683,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1683,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,991.62,,,percent of total billed charges,,
ARGATROBAN 250MG INJ NON-ESRD,2500032165,CDM,636,RC,J0883,HCPCS,4202318201,NDC,,,,outpatient,facility,2.5,GR,1683,1683,0.9,1683,,1193.42,,,percent of total billed charges,,,,,,,,,1683,,,percent of total billed charges,,,5.18,,,fee schedule,,,4.9,,,fee schedule,,,,,,,,,4.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1683,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1683,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1683,,,fee schedule,,,1683,,,percent of total billed charges,,,,,,,,,1683,,,percent of total billed charges,,,1031.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1199.14,,,percent of total billed charges,,,,,,,,,,,,,,,3.57,,,fee schedule,,,3.57,,,fee schedule,,,3.57,,,fee schedule,,,,,,,,,992.97,,,percent of total billed charges,,,548.68,,,per diem,,,1683,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1683,,,percent of total billed charges,,,1430.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,893.84,,,percent of total billed charges,,,1683,,,percent of total billed charges,,,1683,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1135.35,,,percent of total billed charges,,,1361.88,,,percent of total billed charges,,,,,,,,,,,,,,,673.2,,,percent of total billed charges,,,,,,,,,3.24,,,fee schedule,,,2.33,,,fee schedule,,,,,,,,,1683,,,percent of total billed charges,,,,,,,,,,,,,,,134.64,,,percent of total billed charges,,,1683,,,percent of total billed charges,,,,,,,,,,,,,,,1683,,,percent of total billed charges,,,1683,,,percent of total billed charges,,,,,,,,,1.39,,,fee schedule,,,,,,,,,,,,,,,1.2,,,fee schedule,,,1.6,,,fee schedule,,,0.9,,,fee schedule,,,1262.25,,,percent of total billed charges,,,1683,,,percent of total billed charges,,,1683,,,percent of total billed charges,,,1683,,,percent of total billed charges,,,,,,,,,1179.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,841.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,991.62,,,percent of total billed charges,,
ARGATROBAN 250MG INJ NON-ESRD,2500032165,CDM,636,RC,J0883,HCPCS,4202318201,NDC,1859,APC,,outpatient,facility,2.5,GR,1683,1683,0.77,615.98,,,,,,,,0.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.81,,,fee schedule,,,,,,,,,615.98,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,fee schedule,,,,,,,,,,,,,,,0.84,,,fee schedule,,,0.84,,,fee schedule,,,,,,,,,0.8,,,fee schedule,,,0.8,,,fee schedule,,,0.84,,,fee schedule,,,,,,,,,,,,,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.77,,,fee schedule,,,0.86,,,fee schedule,,,0.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,fee schedule,,,0.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,fee schedule,,,,,,,,,1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.8,,,fee schedule,,,0.8,,,fee schedule,,,,,,,,,,,,,,,0.8,,,fee schedule,,,,,,,,,0.8,,,fee schedule,,,0.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,fee schedule,,,,,,,,,,,,,,,0.83,,,fee schedule,,,0.8,,,fee schedule,,,,,,,,,0.8,,,fee schedule,,,,,,,,,0.8,,,fee schedule,,,0.84,,,fee schedule,,,,,,,,
ARGATROBAN 250MG INJ NON-ESRD,2500032165,CDM,636,RC,J0883,HCPCS,4202318201,NDC,436,EAPG,,outpatient,facility,2.5,GR,1683,1683,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DARATUMUMAB 100MG INJ,2500032166,CDM,636,RC,J9145,HCPCS,5789450205,NDC,,,,inpatient,facility,5,GR,2346.79,2346.79,187.74,2346.79,,,,,,,,,,,,,,2346.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2346.79,,,percent of total billed charges,,,,,,,,,2346.79,,,percent of total billed charges,,,1198.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1998.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.07,,,percent of total billed charges,,,,,,,,,,,,,,,2346.79,,,percent of total billed charges,,,1994.77,,,percent of total billed charges,,,,,,,,,,,,,,,2346.79,,,percent of total billed charges,,,1246.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,938.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2346.79,,,percent of total billed charges,,,,,,,,,,,,,,,187.74,,,percent of total billed charges,,,2346.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2346.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1382.73,,,percent of total billed charges,,
DARATUMUMAB 100MG INJ,2500032166,CDM,636,RC,J9145,HCPCS,5789450205,NDC,,,,outpatient,facility,5,GR,2346.79,2346.79,40.51,2346.79,,61.13,,,fee schedule,,,,,,,,,2346.79,,,percent of total billed charges,,,83.57,,,fee schedule,,,79.06,,,fee schedule,,,,,,,,,79.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2346.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2346.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2346.79,,,fee schedule,,,2346.79,,,percent of total billed charges,,,,,,,,,2346.79,,,percent of total billed charges,,,1438.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1672.09,,,percent of total billed charges,,,,,,,,,,,,,,,61.71,,,fee schedule,,,61.71,,,fee schedule,,,61.71,,,fee schedule,,,,,,,,,1384.61,,,percent of total billed charges,,,548.68,,,per diem,,,2346.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2346.79,,,percent of total billed charges,,,1994.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1246.38,,,percent of total billed charges,,,2346.79,,,percent of total billed charges,,,2346.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1583.14,,,percent of total billed charges,,,1899.02,,,percent of total billed charges,,,,,,,,,,,,,,,938.72,,,percent of total billed charges,,,,,,,,,145.82,,,fee schedule,,,104.93,,,fee schedule,,,,,,,,,2346.79,,,percent of total billed charges,,,,,,,,,,,,,,,187.74,,,percent of total billed charges,,,2346.79,,,percent of total billed charges,,,,,,,,,,,,,,,2346.79,,,percent of total billed charges,,,2346.79,,,percent of total billed charges,,,,,,,,,62.32,,,fee schedule,,,,,,,,,,,,,,,54.02,,,fee schedule,,,72.02,,,fee schedule,,,40.51,,,fee schedule,,,66.8,,,fee schedule,,,2346.79,,,percent of total billed charges,,,2346.79,,,percent of total billed charges,,,2346.79,,,percent of total billed charges,,,,,,,,,1645.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1173.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1382.73,,,percent of total billed charges,,
DARATUMUMAB 100MG INJ,2500032166,CDM,636,RC,J9145,HCPCS,5789450205,NDC,9476,APC,,outpatient,facility,5,GR,2346.79,2346.79,62.71,858.93,,,,,,,,67.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,65.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.97,,,fee schedule,,,,,,,,,858.93,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,65.32,,,fee schedule,,,,,,,,,,,,,,,68.59,,,fee schedule,,,68.59,,,fee schedule,,,,,,,,,65.32,,,fee schedule,,,65.32,,,fee schedule,,,68.59,,,fee schedule,,,,,,,,,,,,,,,97.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,65.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.71,,,fee schedule,,,69.89,,,fee schedule,,,68.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.32,,,fee schedule,,,65.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,67.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,65.32,,,fee schedule,,,,,,,,,81.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,81.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,65.32,,,fee schedule,,,65.32,,,fee schedule,,,,,,,,,,,,,,,65.32,,,fee schedule,,,,,,,,,65.32,,,fee schedule,,,67.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.32,,,fee schedule,,,,,,,,,,,,,,,67.93,,,fee schedule,,,65.32,,,fee schedule,,,,,,,,,65.32,,,fee schedule,,,,,,,,,65.32,,,fee schedule,,,68.59,,,fee schedule,,,,,,,,
DARATUMUMAB 100MG INJ,2500032166,CDM,636,RC,J9145,HCPCS,5789450205,NDC,462,EAPG,,outpatient,facility,5,GR,2346.79,2346.79,4530.01,6840.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6840.32,,,fee schedule,,,4530.01,,,fee schedule,,,6081.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DARATUMUMAB 400MG INJ,2500032167,CDM,636,RC,J9145,HCPCS,5789450220,NDC,,,,inpatient,facility,20,ML,9387.11,9387.11,750.97,9387.11,,,,,,,,,,,,,,9387.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9387.11,,,percent of total billed charges,,,,,,,,,9387.11,,,percent of total billed charges,,,4793.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7995,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5632.27,,,percent of total billed charges,,,,,,,,,,,,,,,9387.11,,,percent of total billed charges,,,7979.04,,,percent of total billed charges,,,,,,,,,,,,,,,9387.11,,,percent of total billed charges,,,4985.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3754.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9387.11,,,percent of total billed charges,,,,,,,,,,,,,,,750.97,,,percent of total billed charges,,,9387.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9387.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5530.89,,,percent of total billed charges,,
DARATUMUMAB 400MG INJ,2500032167,CDM,636,RC,J9145,HCPCS,5789450220,NDC,,,,outpatient,facility,20,ML,9387.11,9387.11,40.51,9387.11,,61.13,,,fee schedule,,,,,,,,,9387.11,,,percent of total billed charges,,,83.57,,,fee schedule,,,79.06,,,fee schedule,,,,,,,,,79.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,9387.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9387.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9387.11,,,fee schedule,,,9387.11,,,percent of total billed charges,,,,,,,,,9387.11,,,percent of total billed charges,,,5753.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6688.32,,,percent of total billed charges,,,,,,,,,,,,,,,61.71,,,fee schedule,,,61.71,,,fee schedule,,,61.71,,,fee schedule,,,,,,,,,5538.39,,,percent of total billed charges,,,548.68,,,per diem,,,9387.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9387.11,,,percent of total billed charges,,,7979.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4985.49,,,percent of total billed charges,,,9387.11,,,percent of total billed charges,,,9387.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6332.54,,,percent of total billed charges,,,7596.05,,,percent of total billed charges,,,,,,,,,,,,,,,3754.84,,,percent of total billed charges,,,,,,,,,145.82,,,fee schedule,,,104.93,,,fee schedule,,,,,,,,,9387.11,,,percent of total billed charges,,,,,,,,,,,,,,,750.97,,,percent of total billed charges,,,9387.11,,,percent of total billed charges,,,,,,,,,,,,,,,9387.11,,,percent of total billed charges,,,9387.11,,,percent of total billed charges,,,,,,,,,62.32,,,fee schedule,,,,,,,,,,,,,,,54.02,,,fee schedule,,,72.02,,,fee schedule,,,40.51,,,fee schedule,,,66.8,,,fee schedule,,,9387.11,,,percent of total billed charges,,,9387.11,,,percent of total billed charges,,,9387.11,,,percent of total billed charges,,,,,,,,,6581.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4693.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5530.89,,,percent of total billed charges,,
DARATUMUMAB 400MG INJ,2500032167,CDM,636,RC,J9145,HCPCS,5789450220,NDC,9476,APC,,outpatient,facility,20,ML,9387.11,9387.11,62.71,3435.68,,,,,,,,67.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,65.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.97,,,fee schedule,,,,,,,,,3435.68,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,65.32,,,fee schedule,,,,,,,,,,,,,,,68.59,,,fee schedule,,,68.59,,,fee schedule,,,,,,,,,65.32,,,fee schedule,,,65.32,,,fee schedule,,,68.59,,,fee schedule,,,,,,,,,,,,,,,97.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,65.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.71,,,fee schedule,,,69.89,,,fee schedule,,,68.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.32,,,fee schedule,,,65.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,67.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,65.32,,,fee schedule,,,,,,,,,81.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,81.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,65.32,,,fee schedule,,,65.32,,,fee schedule,,,,,,,,,,,,,,,65.32,,,fee schedule,,,,,,,,,65.32,,,fee schedule,,,67.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.32,,,fee schedule,,,,,,,,,,,,,,,67.93,,,fee schedule,,,65.32,,,fee schedule,,,,,,,,,65.32,,,fee schedule,,,,,,,,,65.32,,,fee schedule,,,68.59,,,fee schedule,,,,,,,,
DARATUMUMAB 400MG INJ,2500032167,CDM,636,RC,J9145,HCPCS,5789450220,NDC,462,EAPG,,outpatient,facility,20,ML,9387.11,9387.11,4530.01,6840.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6840.32,,,fee schedule,,,4530.01,,,fee schedule,,,6081.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TBO-FILGRASTIM 300 MCG INJ,2500032170,CDM,636,RC,J1447,HCPCS,6345991859,NDC,,,,inpatient,facility,1,UN,989.44,989.44,79.16,989.44,,,,,,,,,,,,,,989.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,989.44,,,percent of total billed charges,,,,,,,,,989.44,,,percent of total billed charges,,,505.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,842.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,593.66,,,percent of total billed charges,,,,,,,,,,,,,,,989.44,,,percent of total billed charges,,,841.02,,,percent of total billed charges,,,,,,,,,,,,,,,989.44,,,percent of total billed charges,,,525.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,989.44,,,percent of total billed charges,,,,,,,,,,,,,,,79.16,,,percent of total billed charges,,,989.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,989.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,582.98,,,percent of total billed charges,,
TBO-FILGRASTIM 300 MCG INJ,2500032170,CDM,636,RC,J1447,HCPCS,6345991859,NDC,,,,outpatient,facility,1,UN,989.44,989.44,0.27,989.44,,0.41,,,fee schedule,,,,,,,,,989.44,,,percent of total billed charges,,,0.52,,,fee schedule,,,0.49,,,fee schedule,,,,,,,,,0.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,989.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,989.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,989.44,,,fee schedule,,,989.44,,,percent of total billed charges,,,,,,,,,989.44,,,percent of total billed charges,,,606.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,704.98,,,percent of total billed charges,,,,,,,,,,,,,,,0.44,,,fee schedule,,,0.44,,,fee schedule,,,0.44,,,fee schedule,,,,,,,,,583.77,,,percent of total billed charges,,,548.68,,,per diem,,,989.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,989.44,,,percent of total billed charges,,,841.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,525.49,,,percent of total billed charges,,,989.44,,,percent of total billed charges,,,989.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,667.48,,,percent of total billed charges,,,800.65,,,percent of total billed charges,,,,,,,,,,,,,,,395.78,,,percent of total billed charges,,,,,,,,,0.96,,,fee schedule,,,0.69,,,fee schedule,,,,,,,,,989.44,,,percent of total billed charges,,,,,,,,,,,,,,,79.16,,,percent of total billed charges,,,989.44,,,percent of total billed charges,,,,,,,,,,,,,,,989.44,,,percent of total billed charges,,,989.44,,,percent of total billed charges,,,,,,,,,0.41,,,fee schedule,,,,,,,,,,,,,,,0.35,,,fee schedule,,,0.47,,,fee schedule,,,0.27,,,fee schedule,,,0.42,,,fee schedule,,,989.44,,,percent of total billed charges,,,989.44,,,percent of total billed charges,,,989.44,,,percent of total billed charges,,,,,,,,,693.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,494.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,582.98,,,percent of total billed charges,,
TBO-FILGRASTIM 300 MCG INJ,2500032170,CDM,636,RC,J1447,HCPCS,6345991859,NDC,1748,APC,,outpatient,facility,1,UN,989.44,989.44,0.38,362.14,,,,,,,,0.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,362.14,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.42,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,0.4,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,,,,,,,,0.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.38,,,fee schedule,,,0.43,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.4,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,0.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,fee schedule,,,,,,,,,,,,,,,0.42,,,fee schedule,,,0.4,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,,,,,,,0.4,,,fee schedule,,,0.42,,,fee schedule,,,,,,,,
TBO-FILGRASTIM 300 MCG INJ,2500032170,CDM,636,RC,J1447,HCPCS,6345991859,NDC,438,EAPG,,outpatient,facility,1,UN,989.44,989.44,332.92,502.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,502.71,,,fee schedule,,,332.92,,,fee schedule,,,446.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
METHYLENE BLUE 0.5  10 ML INJ,2500032173,CDM,636,RC,Q9968,HCPCS,517037405,NDC,,,,inpatient,facility,10,UN,773.49,773.49,61.88,773.49,,,,,,,,,,,,,,773.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,773.49,,,percent of total billed charges,,,,,,,,,773.49,,,percent of total billed charges,,,394.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,658.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.09,,,percent of total billed charges,,,,,,,,,,,,,,,773.49,,,percent of total billed charges,,,657.47,,,percent of total billed charges,,,,,,,,,,,,,,,773.49,,,percent of total billed charges,,,410.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,309.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,773.49,,,percent of total billed charges,,,,,,,,,,,,,,,61.88,,,percent of total billed charges,,,773.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,773.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,455.74,,,percent of total billed charges,,
METHYLENE BLUE 0.5  10 ML INJ,2500032173,CDM,636,RC,Q9968,HCPCS,517037405,NDC,,,,outpatient,facility,10,UN,773.49,773.49,5.51,773.49,,548.48,,,percent of total billed charges,,,,,,,,,773.49,,,percent of total billed charges,,,13.82,,,fee schedule,,,13.08,,,fee schedule,,,,,,,,,13.08,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,773.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,773.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,773.49,,,fee schedule,,,773.49,,,percent of total billed charges,,,,,,,,,773.49,,,percent of total billed charges,,,474.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.11,,,percent of total billed charges,,,,,,,,,,,,,,,17.96,,,fee schedule,,,17.96,,,fee schedule,,,17.96,,,fee schedule,,,,,,,,,456.36,,,percent of total billed charges,,,548.68,,,per diem,,,773.49,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,773.49,,,percent of total billed charges,,,657.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,410.8,,,percent of total billed charges,,,773.49,,,percent of total billed charges,,,773.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,521.8,,,percent of total billed charges,,,625.91,,,percent of total billed charges,,,,,,,,,,,,,,,309.4,,,percent of total billed charges,,,,,,,,,19.85,,,fee schedule,,,14.29,,,fee schedule,,,,,,,,,773.49,,,percent of total billed charges,,,,,,,,,,,,,,,61.88,,,percent of total billed charges,,,773.49,,,percent of total billed charges,,,,,,,,,,,,,,,773.49,,,percent of total billed charges,,,773.49,,,percent of total billed charges,,,,,,,,,8.48,,,fee schedule,,,,,,,,,,,,,,,7.35,,,fee schedule,,,9.8,,,fee schedule,,,5.51,,,fee schedule,,,580.12,,,percent of total billed charges,,,773.49,,,percent of total billed charges,,,773.49,,,percent of total billed charges,,,773.49,,,percent of total billed charges,,,,,,,,,542.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,455.74,,,percent of total billed charges,,
METHYLENE BLUE 0.5  10 ML INJ,2500032173,CDM,636,RC,Q9968,HCPCS,517037405,NDC,1446,APC,,outpatient,facility,10,UN,773.49,773.49,8.54,283.1,,,,,,,,9.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,8.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.99,,,fee schedule,,,,,,,,,283.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,8.9,,,fee schedule,,,,,,,,,,,,,,,9.34,,,fee schedule,,,9.34,,,fee schedule,,,,,,,,,8.9,,,fee schedule,,,8.9,,,fee schedule,,,9.34,,,fee schedule,,,,,,,,,,,,,,,13.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,8.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.54,,,fee schedule,,,9.52,,,fee schedule,,,9.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.9,,,fee schedule,,,8.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,9.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,8.9,,,fee schedule,,,,,,,,,11.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,8.9,,,fee schedule,,,8.9,,,fee schedule,,,,,,,,,,,,,,,8.9,,,fee schedule,,,,,,,,,8.9,,,fee schedule,,,9.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.9,,,fee schedule,,,,,,,,,,,,,,,9.26,,,fee schedule,,,8.9,,,fee schedule,,,,,,,,,8.9,,,fee schedule,,,,,,,,,8.9,,,fee schedule,,,9.34,,,fee schedule,,,,,,,,
METHYLENE BLUE 0.5  10 ML INJ,2500032173,CDM,636,RC,Q9968,HCPCS,517037405,NDC,999,EAPG,,outpatient,facility,10,UN,773.49,773.49,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENDAMUSTINE 1 MG (BENDEKA),2500032176,CDM,636,RC,J9034,HCPCS,6345934804,NDC,,,,inpatient,facility,0.04,UN,81.63,81.63,6.53,81.63,,,,,,,,,,,,,,81.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.63,,,percent of total billed charges,,,,,,,,,81.63,,,percent of total billed charges,,,41.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.98,,,percent of total billed charges,,,,,,,,,,,,,,,81.63,,,percent of total billed charges,,,69.39,,,percent of total billed charges,,,,,,,,,,,,,,,81.63,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,81.63,,,percent of total billed charges,,,,,,,,,,,,,,,6.53,,,percent of total billed charges,,,81.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.1,,,percent of total billed charges,,
BENDAMUSTINE 1 MG (BENDEKA),2500032176,CDM,636,RC,J9034,HCPCS,6345934804,NDC,,,,outpatient,facility,0.04,UN,81.63,81.63,6.53,548.68,,13.83,,,fee schedule,,,,,,,,,81.63,,,percent of total billed charges,,,17.67,,,fee schedule,,,16.71,,,fee schedule,,,,,,,,,16.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,81.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,81.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,81.63,,,fee schedule,,,81.63,,,percent of total billed charges,,,,,,,,,81.63,,,percent of total billed charges,,,50.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.16,,,percent of total billed charges,,,,,,,,,,,,,,,14.76,,,fee schedule,,,14.76,,,fee schedule,,,14.76,,,fee schedule,,,,,,,,,48.16,,,percent of total billed charges,,,548.68,,,per diem,,,81.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,81.63,,,percent of total billed charges,,,69.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.35,,,percent of total billed charges,,,81.63,,,percent of total billed charges,,,81.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.07,,,percent of total billed charges,,,66.05,,,percent of total billed charges,,,,,,,,,,,,,,,32.65,,,percent of total billed charges,,,,,,,,,42.83,,,fee schedule,,,30.82,,,fee schedule,,,,,,,,,81.63,,,percent of total billed charges,,,,,,,,,,,,,,,6.53,,,percent of total billed charges,,,81.63,,,percent of total billed charges,,,,,,,,,,,,,,,81.63,,,percent of total billed charges,,,81.63,,,percent of total billed charges,,,,,,,,,18.3,,,fee schedule,,,,,,,,,,,,,,,15.86,,,fee schedule,,,21.15,,,fee schedule,,,11.9,,,fee schedule,,,14.12,,,fee schedule,,,81.63,,,percent of total billed charges,,,81.63,,,percent of total billed charges,,,81.63,,,percent of total billed charges,,,,,,,,,57.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.81,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,48.1,,,percent of total billed charges,,
BENDAMUSTINE 1 MG (BENDEKA),2500032176,CDM,636,RC,J9034,HCPCS,6345934804,NDC,1861,APC,,outpatient,facility,0.04,UN,81.63,81.63,12.91,29.88,,,,,,,,13.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,13.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.58,,,fee schedule,,,,,,,,,29.88,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,13.45,,,fee schedule,,,,,,,,,,,,,,,14.12,,,fee schedule,,,14.12,,,fee schedule,,,,,,,,,13.45,,,fee schedule,,,13.45,,,fee schedule,,,14.12,,,fee schedule,,,,,,,,,,,,,,,20.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,13.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.91,,,fee schedule,,,14.39,,,fee schedule,,,14.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.45,,,fee schedule,,,13.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,13.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,13.45,,,fee schedule,,,,,,,,,16.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,13.45,,,fee schedule,,,13.45,,,fee schedule,,,,,,,,,,,,,,,13.45,,,fee schedule,,,,,,,,,13.45,,,fee schedule,,,13.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.45,,,fee schedule,,,,,,,,,,,,,,,13.99,,,fee schedule,,,13.45,,,fee schedule,,,,,,,,,13.45,,,fee schedule,,,,,,,,,13.45,,,fee schedule,,,14.12,,,fee schedule,,,,,,,,
BENDAMUSTINE 1 MG (BENDEKA),2500032176,CDM,636,RC,J9034,HCPCS,6345934804,NDC,461,EAPG,,outpatient,facility,0.04,UN,81.63,81.63,2278.01,3439.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3439.8,,,fee schedule,,,2278.01,,,fee schedule,,,3058,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,2278.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SUGAMMADEX 200  MG/2 ML INJ,2500032179,CDM,250,RC,6542312,NDC,,,,,,inpatient,facility,2,UN,427.88,427.88,34.23,427.88,,,,,,,,,,,,,,427.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,427.88,,,percent of total billed charges,,,,,,,,,427.88,,,percent of total billed charges,,,218.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.73,,,percent of total billed charges,,,,,,,,,,,,,,,427.88,,,percent of total billed charges,,,363.7,,,percent of total billed charges,,,,,,,,,,,,,,,427.88,,,percent of total billed charges,,,227.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,427.88,,,percent of total billed charges,,,,,,,,,,,,,,,34.23,,,percent of total billed charges,,,427.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,427.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.11,,,percent of total billed charges,,
SUGAMMADEX 200  MG/2 ML INJ,2500032179,CDM,250,RC,6542312,NDC,,,,,,outpatient,facility,2,UN,427.88,427.88,34.23,548.68,,303.41,,,percent of total billed charges,,,104.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,427.88,,,percent of total billed charges,,,268.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,300.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,300.8,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,427.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,156.6,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,427.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,427.88,,,fee schedule,,,427.88,,,percent of total billed charges,,,,,,,,,427.88,,,percent of total billed charges,,,262.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,252.45,,,percent of total billed charges,,,548.68,,,per diem,,,427.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,427.88,,,percent of total billed charges,,,363.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,227.25,,,percent of total billed charges,,,427.88,,,percent of total billed charges,,,427.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288.65,,,percent of total billed charges,,,346.24,,,percent of total billed charges,,,,,,,,,,,,,,,171.15,,,percent of total billed charges,,,,,,,,,171.15,,,percent of total billed charges,,,171.15,,,percent of total billed charges,,,,,,,,,427.88,,,percent of total billed charges,,,427.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,427.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,34.23,,,percent of total billed charges,,,427.88,,,percent of total billed charges,,,,,,,,,,,,,,,427.88,,,percent of total billed charges,,,427.88,,,percent of total billed charges,,,,,,,,,171.15,,,percent of total billed charges,,,,,,,,,,,,,,,171.15,,,percent of total billed charges,,,171.15,,,percent of total billed charges,,,171.15,,,percent of total billed charges,,,320.91,,,percent of total billed charges,,,427.88,,,percent of total billed charges,,,427.88,,,percent of total billed charges,,,427.88,,,percent of total billed charges,,,,,,,,,299.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.94,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,252.11,,,percent of total billed charges,,
SUGAMMADEX 200  MG/2 ML INJ,2500032179,CDM,250,RC,6542312,NDC,999,EAPG,,,,outpatient,facility,2,UN,427.88,427.88,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA 20000 U ESRD,2500032192,CDM,634,RC,Q4081,HCPCS,5551347810,NDC,,,,inpatient,facility,1,UN,727.98,727.98,58.24,727.98,,,,,,,,,,,,,,727.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,727.98,,,percent of total billed charges,,,,,,,,,727.98,,,percent of total billed charges,,,371.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,620.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,436.79,,,percent of total billed charges,,,,,,,,,,,,,,,727.98,,,percent of total billed charges,,,618.78,,,percent of total billed charges,,,,,,,,,,,,,,,727.98,,,percent of total billed charges,,,386.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,291.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,727.98,,,percent of total billed charges,,,,,,,,,,,,,,,58.24,,,percent of total billed charges,,,727.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,727.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,428.93,,,percent of total billed charges,,
EPOETIN ALFA 20000 U ESRD,2500032192,CDM,634,RC,Q4081,HCPCS,5551347810,NDC,,,,outpatient,facility,1,UN,727.98,727.98,0.85,727.98,,516.21,,,percent of total billed charges,,,177.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,727.98,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,727.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,266.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,727.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,727.98,,,fee schedule,,,727.98,,,percent of total billed charges,,,,,,,,,727.98,,,percent of total billed charges,,,446.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,518.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,429.51,,,percent of total billed charges,,,548.68,,,per diem,,,727.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,727.98,,,percent of total billed charges,,,618.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,386.63,,,percent of total billed charges,,,727.98,,,percent of total billed charges,,,727.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,491.1,,,percent of total billed charges,,,589.08,,,percent of total billed charges,,,,,,,,,,,,,,,291.19,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,727.98,,,percent of total billed charges,,,727.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,727.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,58.24,,,percent of total billed charges,,,727.98,,,percent of total billed charges,,,,,,,,,,,,,,,727.98,,,percent of total billed charges,,,727.98,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.85,,,fee schedule,,,727.98,,,percent of total billed charges,,,727.98,,,percent of total billed charges,,,727.98,,,percent of total billed charges,,,,,,,,,510.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,428.93,,,percent of total billed charges,,
EPOETIN ALFA 20000 U ESRD,2500032192,CDM,634,RC,Q4081,HCPCS,5551347810,NDC,436,EAPG,,outpatient,facility,1,UN,727.98,727.98,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MIDAZOLAM HCL 5MG/5ML VIAL,2500032212,CDM,636,RC,J2250,HCPCS,409230505,NDC,,,,inpatient,facility,5,ML,3.76,3.76,0.3,3.76,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.26,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,
MIDAZOLAM HCL 5MG/5ML VIAL,2500032212,CDM,636,RC,J2250,HCPCS,409230505,NDC,,,,outpatient,facility,5,ML,3.76,3.76,0.08,548.68,,2.67,,,percent of total billed charges,,,0.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.76,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.38,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.08,,,fee schedule,,,3.76,,,fee schedule,,,3.76,,,percent of total billed charges,,,,,,,,,3.76,,,percent of total billed charges,,,2.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,2.22,,,percent of total billed charges,,,548.68,,,per diem,,,3.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.76,,,percent of total billed charges,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.54,,,percent of total billed charges,,,3.04,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,3.76,,,percent of total billed charges,,,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.3,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.14,,,fee schedule,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,3.76,,,percent of total billed charges,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.88,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2.22,,,percent of total billed charges,,
MIDAZOLAM HCL 5MG/5ML VIAL,2500032212,CDM,636,RC,J2250,HCPCS,409230505,NDC,496,EAPG,,outpatient,facility,5,ML,3.76,3.76,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NALOXONE 2MG/2ML PREFIL SYRNG,2500032214,CDM,636,RC,J2310,HCPCS,7632933691,NDC,,,,inpatient,facility,2,ML,108.9,108.9,8.71,108.9,,,,,,,,,,,,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.9,,,percent of total billed charges,,,,,,,,,108.9,,,percent of total billed charges,,,55.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.34,,,percent of total billed charges,,,,,,,,,,,,,,,108.9,,,percent of total billed charges,,,92.56,,,percent of total billed charges,,,,,,,,,,,,,,,108.9,,,percent of total billed charges,,,57.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,,8.71,,,percent of total billed charges,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.16,,,percent of total billed charges,,
NALOXONE 2MG/2ML PREFIL SYRNG,2500032214,CDM,636,RC,J2310,HCPCS,7632933691,NDC,,,,outpatient,facility,2,ML,108.9,108.9,8.71,548.68,,77.22,,,percent of total billed charges,,,26.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,108.9,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,39.86,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,8.77,,,fee schedule,,,108.9,,,fee schedule,,,108.9,,,percent of total billed charges,,,,,,,,,108.9,,,percent of total billed charges,,,66.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,64.25,,,percent of total billed charges,,,548.68,,,per diem,,,108.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,108.9,,,percent of total billed charges,,,92.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.84,,,percent of total billed charges,,,108.9,,,percent of total billed charges,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.46,,,percent of total billed charges,,,88.12,,,percent of total billed charges,,,,,,,,,,,,,,,43.56,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,108.9,,,percent of total billed charges,,,108.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,108.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.71,,,percent of total billed charges,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,,108.9,,,percent of total billed charges,,,108.9,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,9.69,,,fee schedule,,,108.9,,,percent of total billed charges,,,108.9,,,percent of total billed charges,,,108.9,,,percent of total billed charges,,,,,,,,,76.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,64.16,,,percent of total billed charges,,
NALOXONE 2MG/2ML PREFIL SYRNG,2500032214,CDM,636,RC,J2310,HCPCS,7632933691,NDC,435,EAPG,,outpatient,facility,2,ML,108.9,108.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDO 1 /EPI 1 100000 10 ML VL,2500032269,CDM,636,RC,J2004,HCPCS,6332348217,NDC,,,,inpatient,facility,10,UN,11.45,11.45,0.92,11.45,,,,,,,,,,,,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.45,,,percent of total billed charges,,,,,,,,,11.45,,,percent of total billed charges,,,5.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.87,,,percent of total billed charges,,,,,,,,,,,,,,,11.45,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,11.45,,,percent of total billed charges,,,6.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.92,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.75,,,percent of total billed charges,,
LIDO 1 /EPI 1 100000 10 ML VL,2500032269,CDM,636,RC,J2004,HCPCS,6332348217,NDC,,,,outpatient,facility,10,UN,11.45,11.45,0.92,548.68,,8.12,,,percent of total billed charges,,,2.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,11.45,,,percent of total billed charges,,,7.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.05,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.19,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,11.45,,,fee schedule,,,11.45,,,percent of total billed charges,,,,,,,,,11.45,,,percent of total billed charges,,,7.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.16,,,percent of total billed charges,,,,,,,,,,,,,,,6.18,,,percent of total billed charges,,,5.95,,,percent of total billed charges,,,6.3,,,percent of total billed charges,,,,,,,,,6.76,,,percent of total billed charges,,,548.68,,,per diem,,,11.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11.45,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.08,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,9.27,,,percent of total billed charges,,,,,,,,,,,,,,,4.58,,,percent of total billed charges,,,,,,,,,4.24,,,percent of total billed charges,,,4.24,,,percent of total billed charges,,,,,,,,,11.45,,,percent of total billed charges,,,11.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.92,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,,,,,,,,,,,,,11.45,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,,,,,,,10.65,,,percent of total billed charges,,,,,,,,,,,,,,,10.65,,,percent of total billed charges,,,10.65,,,percent of total billed charges,,,10.65,,,percent of total billed charges,,,8.59,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,11.45,,,percent of total billed charges,,,,,,,,,8.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.75,,,percent of total billed charges,,
LIDO 1 /EPI 1 100000 10 ML VL,2500032269,CDM,636,RC,J2004,HCPCS,6332348217,NDC,999,EAPG,,outpatient,facility,10,UN,11.45,11.45,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEFTOLOZANE/TAZOBACTAM 1G/0.5G,2500032319,CDM,636,RC,J0695,HCPCS,6791903001,NDC,,,,inpatient,facility,1.5,GR,523.54,523.54,41.88,523.54,,,,,,,,,,,,,,523.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.54,,,percent of total billed charges,,,,,,,,,523.54,,,percent of total billed charges,,,267.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,445.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,314.12,,,percent of total billed charges,,,,,,,,,,,,,,,523.54,,,percent of total billed charges,,,445.01,,,percent of total billed charges,,,,,,,,,,,,,,,523.54,,,percent of total billed charges,,,278.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,523.54,,,percent of total billed charges,,,,,,,,,,,,,,,41.88,,,percent of total billed charges,,,523.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,523.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.47,,,percent of total billed charges,,
CEFTOLOZANE/TAZOBACTAM 1G/0.5G,2500032319,CDM,636,RC,J0695,HCPCS,6791903001,NDC,,,,outpatient,facility,1.5,GR,523.54,523.54,4.34,548.68,,371.24,,,percent of total billed charges,,,,,,,,,523.54,,,percent of total billed charges,,,10.7,,,fee schedule,,,10.12,,,fee schedule,,,,,,,,,10.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,523.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,523.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,523.54,,,fee schedule,,,523.54,,,percent of total billed charges,,,,,,,,,523.54,,,percent of total billed charges,,,320.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.02,,,percent of total billed charges,,,,,,,,,,,,,,,7.37,,,fee schedule,,,7.37,,,fee schedule,,,7.37,,,fee schedule,,,,,,,,,308.89,,,percent of total billed charges,,,548.68,,,per diem,,,523.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,523.54,,,percent of total billed charges,,,445.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,278.05,,,percent of total billed charges,,,523.54,,,percent of total billed charges,,,523.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,353.18,,,percent of total billed charges,,,423.65,,,percent of total billed charges,,,,,,,,,,,,,,,209.42,,,percent of total billed charges,,,,,,,,,15.6,,,fee schedule,,,11.23,,,fee schedule,,,,,,,,,523.54,,,percent of total billed charges,,,,,,,,,,,,,,,41.88,,,percent of total billed charges,,,523.54,,,percent of total billed charges,,,,,,,,,,,,,,,523.54,,,percent of total billed charges,,,523.54,,,percent of total billed charges,,,,,,,,,6.67,,,fee schedule,,,,,,,,,,,,,,,5.78,,,fee schedule,,,7.71,,,fee schedule,,,4.34,,,fee schedule,,,8.55,,,fee schedule,,,523.54,,,percent of total billed charges,,,523.54,,,percent of total billed charges,,,523.54,,,percent of total billed charges,,,,,,,,,367.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,308.47,,,percent of total billed charges,,
CEFTOLOZANE/TAZOBACTAM 1G/0.5G,2500032319,CDM,636,RC,J0695,HCPCS,6791903001,NDC,9452,APC,,outpatient,facility,1.5,GR,523.54,523.54,7.82,191.62,,,,,,,,8.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,8.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.23,,,fee schedule,,,,,,,,,191.62,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,fee schedule,,,,,,,,,,,,,,,8.56,,,fee schedule,,,8.56,,,fee schedule,,,,,,,,,8.15,,,fee schedule,,,8.15,,,fee schedule,,,8.56,,,fee schedule,,,,,,,,,,,,,,,12.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,8.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.82,,,fee schedule,,,8.72,,,fee schedule,,,8.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,fee schedule,,,8.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,8.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,fee schedule,,,,,,,,,10.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,10.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,8.15,,,fee schedule,,,8.15,,,fee schedule,,,,,,,,,,,,,,,8.15,,,fee schedule,,,,,,,,,8.15,,,fee schedule,,,8.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.15,,,fee schedule,,,,,,,,,,,,,,,8.48,,,fee schedule,,,8.15,,,fee schedule,,,,,,,,,8.15,,,fee schedule,,,,,,,,,8.15,,,fee schedule,,,8.56,,,fee schedule,,,,,,,,
CEFTOLOZANE/TAZOBACTAM 1G/0.5G,2500032319,CDM,636,RC,J0695,HCPCS,6791903001,NDC,437,EAPG,,outpatient,facility,1.5,GR,523.54,523.54,156.28,235.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.98,,,fee schedule,,,156.28,,,fee schedule,,,209.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,156.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMINO ACIDS 5  D15 2000ML LYTE,2500032323,CDM,258,RC,338112304,NDC,,,,,,inpatient,facility,2000,UN,282.68,282.68,22.61,282.68,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,282.68,,,percent of total billed charges,,,144.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.61,,,percent of total billed charges,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,240.28,,,percent of total billed charges,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,150.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,22.61,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.56,,,percent of total billed charges,,
AMINO ACIDS 5  D15 2000ML LYTE,2500032323,CDM,258,RC,338112304,NDC,,,,,,outpatient,facility,2000,UN,282.68,282.68,22.61,548.68,,200.45,,,percent of total billed charges,,,68.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,282.68,,,percent of total billed charges,,,177.16,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,198.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,198.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,103.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,282.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,282.68,,,fee schedule,,,282.68,,,percent of total billed charges,,,,,,,,,282.68,,,percent of total billed charges,,,173.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,166.78,,,percent of total billed charges,,,548.68,,,per diem,,,282.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,282.68,,,percent of total billed charges,,,240.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.13,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.7,,,percent of total billed charges,,,228.74,,,percent of total billed charges,,,,,,,,,,,,,,,113.07,,,percent of total billed charges,,,,,,,,,113.07,,,percent of total billed charges,,,113.07,,,percent of total billed charges,,,,,,,,,282.68,,,percent of total billed charges,,,282.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,282.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.61,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,,,,,,,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,113.07,,,percent of total billed charges,,,,,,,,,,,,,,,113.07,,,percent of total billed charges,,,113.07,,,percent of total billed charges,,,113.07,,,percent of total billed charges,,,212.01,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,282.68,,,percent of total billed charges,,,,,,,,,198.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,166.56,,,percent of total billed charges,,
AMINO ACIDS 5  D15 2000ML LYTE,2500032323,CDM,258,RC,338112304,NDC,999,EAPG,,,,outpatient,facility,2000,UN,282.68,282.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCOPOLAMINE 1 MG PATCH,2500032329,CDM,637,RC,5074250524,NDC,,,,,,inpatient,facility,1,UN,75.8,75.8,6.06,75.8,,,,,,,,,,,,,,75.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.8,,,percent of total billed charges,,,,,,,,,75.8,,,percent of total billed charges,,,38.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.48,,,percent of total billed charges,,,,,,,,,,,,,,,75.8,,,percent of total billed charges,,,64.43,,,percent of total billed charges,,,,,,,,,,,,,,,75.8,,,percent of total billed charges,,,40.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,75.8,,,percent of total billed charges,,,,,,,,,,,,,,,6.06,,,percent of total billed charges,,,75.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,75.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.66,,,percent of total billed charges,,
SCOPOLAMINE 1 MG PATCH,2500032329,CDM,637,RC,5074250524,NDC,,,,,,outpatient,facility,1,UN,75.8,75.8,6.06,548.68,,53.75,,,percent of total billed charges,,,18.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,75.8,,,percent of total billed charges,,,47.5,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,53.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,53.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,75.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,27.74,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,75.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,75.8,,,fee schedule,,,75.8,,,percent of total billed charges,,,,,,,,,75.8,,,percent of total billed charges,,,46.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.01,,,percent of total billed charges,,,,,,,,,,,,,,,40.93,,,percent of total billed charges,,,39.42,,,percent of total billed charges,,,41.69,,,percent of total billed charges,,,,,,,,,44.72,,,percent of total billed charges,,,548.68,,,per diem,,,75.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,75.8,,,percent of total billed charges,,,64.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.26,,,percent of total billed charges,,,75.8,,,percent of total billed charges,,,75.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.13,,,percent of total billed charges,,,61.34,,,percent of total billed charges,,,,,,,,,,,,,,,30.32,,,percent of total billed charges,,,,,,,,,28.05,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,,,,,,,75.8,,,percent of total billed charges,,,75.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,75.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.06,,,percent of total billed charges,,,75.8,,,percent of total billed charges,,,,,,,,,,,,,,,75.8,,,percent of total billed charges,,,75.8,,,percent of total billed charges,,,,,,,,,70.51,,,percent of total billed charges,,,,,,,,,,,,,,,70.51,,,percent of total billed charges,,,70.51,,,percent of total billed charges,,,70.51,,,percent of total billed charges,,,56.85,,,percent of total billed charges,,,75.8,,,percent of total billed charges,,,75.8,,,percent of total billed charges,,,75.8,,,percent of total billed charges,,,,,,,,,53.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,44.66,,,percent of total billed charges,,
SCOPOLAMINE 1 MG PATCH,2500032329,CDM,637,RC,5074250524,NDC,999,EAPG,,,,outpatient,facility,1,UN,75.8,75.8,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACYCLOVIR ORAL SUSP 40 MG/ML,2500032333,CDM,637,RC,7095418810,NDC,,,,,,inpatient,facility,1,UN,3.1,3.1,0.25,3.1,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,3.1,,,percent of total billed charges,,,1.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.83,,,percent of total billed charges,,
ACYCLOVIR ORAL SUSP 40 MG/ML,2500032333,CDM,637,RC,7095418810,NDC,,,,,,outpatient,facility,1,UN,3.1,3.1,0.25,548.68,,2.2,,,percent of total billed charges,,,0.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,3.1,,,percent of total billed charges,,,1.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,2.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,2.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,1.13,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3.1,,,fee schedule,,,3.1,,,percent of total billed charges,,,,,,,,,3.1,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.21,,,percent of total billed charges,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,1.61,,,percent of total billed charges,,,1.71,,,percent of total billed charges,,,,,,,,,1.83,,,percent of total billed charges,,,548.68,,,per diem,,,3.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3.1,,,percent of total billed charges,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.09,,,percent of total billed charges,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,,,,,,,1.15,,,percent of total billed charges,,,1.15,,,percent of total billed charges,,,,,,,,,3.1,,,percent of total billed charges,,,3.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.25,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,2.88,,,percent of total billed charges,,,,,,,,,,,,,,,2.88,,,percent of total billed charges,,,2.88,,,percent of total billed charges,,,2.88,,,percent of total billed charges,,,2.33,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,3.1,,,percent of total billed charges,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.55,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.83,,,percent of total billed charges,,
ACYCLOVIR ORAL SUSP 40 MG/ML,2500032333,CDM,637,RC,7095418810,NDC,999,EAPG,,,,outpatient,facility,1,UN,3.1,3.1,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LACTIC ACID 5  LOTN 240 ML BTL,2500032337,CDM,637,RC,1063128605,NDC,,,,,,inpatient,facility,240,UN,17.6,17.6,1.41,17.6,,,,,,,,,,,,,,17.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.6,,,percent of total billed charges,,,,,,,,,17.6,,,percent of total billed charges,,,8.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,,,,,,,,,,,17.6,,,percent of total billed charges,,,14.96,,,percent of total billed charges,,,,,,,,,,,,,,,17.6,,,percent of total billed charges,,,9.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,17.6,,,percent of total billed charges,,,,,,,,,,,,,,,1.41,,,percent of total billed charges,,,17.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.37,,,percent of total billed charges,,
LACTIC ACID 5  LOTN 240 ML BTL,2500032337,CDM,637,RC,1063128605,NDC,,,,,,outpatient,facility,240,UN,17.6,17.6,1.41,548.68,,12.48,,,percent of total billed charges,,,4.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,17.6,,,percent of total billed charges,,,11.03,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,12.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,12.37,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,17.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.44,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,17.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,17.6,,,fee schedule,,,17.6,,,percent of total billed charges,,,,,,,,,17.6,,,percent of total billed charges,,,10.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.54,,,percent of total billed charges,,,,,,,,,,,,,,,9.5,,,percent of total billed charges,,,9.15,,,percent of total billed charges,,,9.68,,,percent of total billed charges,,,,,,,,,10.38,,,percent of total billed charges,,,548.68,,,per diem,,,17.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,17.6,,,percent of total billed charges,,,14.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.35,,,percent of total billed charges,,,17.6,,,percent of total billed charges,,,17.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.87,,,percent of total billed charges,,,14.24,,,percent of total billed charges,,,,,,,,,,,,,,,7.04,,,percent of total billed charges,,,,,,,,,6.51,,,percent of total billed charges,,,6.51,,,percent of total billed charges,,,,,,,,,17.6,,,percent of total billed charges,,,17.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.41,,,percent of total billed charges,,,17.6,,,percent of total billed charges,,,,,,,,,,,,,,,17.6,,,percent of total billed charges,,,17.6,,,percent of total billed charges,,,,,,,,,16.37,,,percent of total billed charges,,,,,,,,,,,,,,,16.37,,,percent of total billed charges,,,16.37,,,percent of total billed charges,,,16.37,,,percent of total billed charges,,,13.2,,,percent of total billed charges,,,17.6,,,percent of total billed charges,,,17.6,,,percent of total billed charges,,,17.6,,,percent of total billed charges,,,,,,,,,12.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10.37,,,percent of total billed charges,,
LACTIC ACID 5  LOTN 240 ML BTL,2500032337,CDM,637,RC,1063128605,NDC,999,EAPG,,,,outpatient,facility,240,UN,17.6,17.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BENZOCAINE 20  GEL SWAB,2500032339,CDM,637,RC,5416292629,NDC,,,,,,inpatient,facility,1,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
BENZOCAINE 20  GEL SWAB,2500032339,CDM,637,RC,5416292629,NDC,,,,,,outpatient,facility,1,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
BENZOCAINE 20  GEL SWAB,2500032339,CDM,637,RC,5416292629,NDC,999,EAPG,,,,outpatient,facility,1,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CLINDAMYCIN SUSP 15 MG/ML UDL,2500032346,CDM,637,RC,5976200161,NDC,,,,,,inpatient,facility,1,UN,2.04,2.04,0.16,2.04,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,
CLINDAMYCIN SUSP 15 MG/ML UDL,2500032346,CDM,637,RC,5976200161,NDC,,,,,,outpatient,facility,1,UN,2.04,2.04,0.16,548.68,,1.45,,,percent of total billed charges,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.04,,,percent of total billed charges,,,1.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.75,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.04,,,fee schedule,,,2.04,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,1.2,,,percent of total billed charges,,,548.68,,,per diem,,,2.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.04,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,0.75,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,2.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.2,,,percent of total billed charges,,
CLINDAMYCIN SUSP 15 MG/ML UDL,2500032346,CDM,637,RC,5976200161,NDC,999,EAPG,,,,outpatient,facility,1,UN,2.04,2.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DILTIAZEM/NS 125 MG/125 ML BAG,2500032353,CDM,250,RC,J3490,HCPCS,7219660551,NDC,,,,inpatient,facility,125,UN,53.03,53.03,4.24,53.03,,,,,,,,,,,,,,53.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,,percent of total billed charges,,,,,,,,,53.03,,,percent of total billed charges,,,27.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.82,,,percent of total billed charges,,,,,,,,,,,,,,,53.03,,,percent of total billed charges,,,45.08,,,percent of total billed charges,,,,,,,,,,,,,,,53.03,,,percent of total billed charges,,,28.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,,percent of total billed charges,,,,,,,,,,,,,,,4.24,,,percent of total billed charges,,,53.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.25,,,percent of total billed charges,,
DILTIAZEM/NS 125 MG/125 ML BAG,2500032353,CDM,250,RC,J3490,HCPCS,7219660551,NDC,,,,outpatient,facility,125,UN,53.03,53.03,1.2,548.68,,37.6,,,percent of total billed charges,,,12.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,53.03,,,percent of total billed charges,,,33.23,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,37.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,37.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,19.41,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,,,,,,service not payable,53.03,,,fee schedule,,,53.03,,,percent of total billed charges,,,,,,,,,53.03,,,percent of total billed charges,,,32.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.78,,,percent of total billed charges,,,,,,,,,,,,,,,53.03,,,percent of total billed charges,,,53.03,,,percent of total billed charges,,,53.03,,,percent of total billed charges,,,,,,,,,31.29,,,percent of total billed charges,,,548.68,,,per diem,,,53.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,53.03,,,percent of total billed charges,,,45.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.16,,,percent of total billed charges,,,1.2,,,fee schedule,,,1.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.77,,,percent of total billed charges,,,42.91,,,percent of total billed charges,,,,,,,,,,,,,,,21.21,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,53.03,,,percent of total billed charges,,,53.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,53.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.24,,,percent of total billed charges,,,53.03,,,percent of total billed charges,,,,,,,,,,,,,,,53.03,,,percent of total billed charges,,,53.03,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,39.77,,,percent of total billed charges,,,53.03,,,percent of total billed charges,,,53.03,,,percent of total billed charges,,,53.03,,,percent of total billed charges,,,,,,,,,37.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.52,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,31.25,,,percent of total billed charges,,
DILTIAZEM/NS 125 MG/125 ML BAG,2500032353,CDM,250,RC,J3490,HCPCS,7219660551,NDC,435,EAPG,,outpatient,facility,125,UN,53.03,53.03,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EMOLLIENT LOTION 473 ML BOTTLE,2500032356,CDM,637,RC,5280048856,NDC,,,,,,inpatient,facility,473,UN,7.94,7.94,0.64,7.94,,,,,,,,,,,,,,7.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.94,,,percent of total billed charges,,,,,,,,,7.94,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.76,,,percent of total billed charges,,,,,,,,,,,,,,,7.94,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,,,,,,,,,,,,,7.94,,,percent of total billed charges,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.94,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,7.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,
EMOLLIENT LOTION 473 ML BOTTLE,2500032356,CDM,637,RC,5280048856,NDC,,,,,,outpatient,facility,473,UN,7.94,7.94,0.64,548.68,,5.63,,,percent of total billed charges,,,1.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.94,,,percent of total billed charges,,,4.98,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.91,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.94,,,fee schedule,,,7.94,,,percent of total billed charges,,,,,,,,,7.94,,,percent of total billed charges,,,4.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.66,,,percent of total billed charges,,,,,,,,,,,,,,,4.29,,,percent of total billed charges,,,4.13,,,percent of total billed charges,,,4.37,,,percent of total billed charges,,,,,,,,,4.68,,,percent of total billed charges,,,548.68,,,per diem,,,7.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.94,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,7.94,,,percent of total billed charges,,,7.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.36,,,percent of total billed charges,,,6.43,,,percent of total billed charges,,,,,,,,,,,,,,,3.18,,,percent of total billed charges,,,,,,,,,2.94,,,percent of total billed charges,,,2.94,,,percent of total billed charges,,,,,,,,,7.94,,,percent of total billed charges,,,7.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.64,,,percent of total billed charges,,,7.94,,,percent of total billed charges,,,,,,,,,,,,,,,7.94,,,percent of total billed charges,,,7.94,,,percent of total billed charges,,,,,,,,,7.39,,,percent of total billed charges,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,7.39,,,percent of total billed charges,,,5.96,,,percent of total billed charges,,,7.94,,,percent of total billed charges,,,7.94,,,percent of total billed charges,,,7.94,,,percent of total billed charges,,,,,,,,,5.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.68,,,percent of total billed charges,,
EMOLLIENT LOTION 473 ML BOTTLE,2500032356,CDM,637,RC,5280048856,NDC,999,EAPG,,,,outpatient,facility,473,UN,7.94,7.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EMTRICITABINE/TENOFOV/ALAFENAM,2500032357,CDM,637,RC,6195820021,NDC,,,,,,inpatient,facility,1,UN,242.25,242.25,19.38,242.25,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,,,,,,,242.25,,,percent of total billed charges,,,123.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,205.91,,,percent of total billed charges,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,128.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,19.38,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.73,,,percent of total billed charges,,
EMTRICITABINE/TENOFOV/ALAFENAM,2500032357,CDM,637,RC,6195820021,NDC,,,,,,outpatient,facility,1,UN,242.25,242.25,19.38,548.68,,171.78,,,percent of total billed charges,,,59.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,242.25,,,percent of total billed charges,,,151.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,170.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,170.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,88.66,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,242.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,242.25,,,fee schedule,,,242.25,,,percent of total billed charges,,,,,,,,,242.25,,,percent of total billed charges,,,148.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.6,,,percent of total billed charges,,,,,,,,,,,,,,,130.81,,,percent of total billed charges,,,125.97,,,percent of total billed charges,,,133.24,,,percent of total billed charges,,,,,,,,,142.93,,,percent of total billed charges,,,548.68,,,per diem,,,242.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,242.25,,,percent of total billed charges,,,205.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,128.66,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.42,,,percent of total billed charges,,,196.03,,,percent of total billed charges,,,,,,,,,,,,,,,96.9,,,percent of total billed charges,,,,,,,,,89.63,,,percent of total billed charges,,,89.63,,,percent of total billed charges,,,,,,,,,242.25,,,percent of total billed charges,,,242.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,242.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.38,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,242.25,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,,,,,,,225.34,,,percent of total billed charges,,,,,,,,,,,,,,,225.34,,,percent of total billed charges,,,225.34,,,percent of total billed charges,,,225.34,,,percent of total billed charges,,,181.69,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,,,,,,,169.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.13,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,142.73,,,percent of total billed charges,,
EMTRICITABINE/TENOFOV/ALAFENAM,2500032357,CDM,637,RC,6195820021,NDC,999,EAPG,,,,outpatient,facility,1,UN,242.25,242.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FAMOTIDINE SUSP 8 MG/ML UDL,2500032363,CDM,637,RC,6818015001,NDC,,,,,,inpatient,facility,1,UN,11.68,11.68,0.93,11.68,,,,,,,,,,,,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.68,,,percent of total billed charges,,,,,,,,,11.68,,,percent of total billed charges,,,5.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.01,,,percent of total billed charges,,,,,,,,,,,,,,,11.68,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,11.68,,,percent of total billed charges,,,6.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,0.93,,,percent of total billed charges,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.88,,,percent of total billed charges,,
FAMOTIDINE SUSP 8 MG/ML UDL,2500032363,CDM,637,RC,6818015001,NDC,,,,,,outpatient,facility,1,UN,11.68,11.68,0.93,548.68,,8.28,,,percent of total billed charges,,,2.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,11.68,,,percent of total billed charges,,,7.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,8.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,8.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,4.27,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,11.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,11.68,,,fee schedule,,,11.68,,,percent of total billed charges,,,,,,,,,11.68,,,percent of total billed charges,,,7.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.32,,,percent of total billed charges,,,,,,,,,,,,,,,6.31,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,6.42,,,percent of total billed charges,,,,,,,,,6.89,,,percent of total billed charges,,,548.68,,,per diem,,,11.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,11.68,,,percent of total billed charges,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.2,,,percent of total billed charges,,,11.68,,,percent of total billed charges,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.88,,,percent of total billed charges,,,9.45,,,percent of total billed charges,,,,,,,,,,,,,,,4.67,,,percent of total billed charges,,,,,,,,,4.32,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,,,,,,,11.68,,,percent of total billed charges,,,11.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,11.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.93,,,percent of total billed charges,,,11.68,,,percent of total billed charges,,,,,,,,,,,,,,,11.68,,,percent of total billed charges,,,11.68,,,percent of total billed charges,,,,,,,,,10.86,,,percent of total billed charges,,,,,,,,,,,,,,,10.86,,,percent of total billed charges,,,10.86,,,percent of total billed charges,,,10.86,,,percent of total billed charges,,,8.76,,,percent of total billed charges,,,11.68,,,percent of total billed charges,,,11.68,,,percent of total billed charges,,,11.68,,,percent of total billed charges,,,,,,,,,8.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,6.88,,,percent of total billed charges,,
FAMOTIDINE SUSP 8 MG/ML UDL,2500032363,CDM,637,RC,6818015001,NDC,999,EAPG,,,,outpatient,facility,1,UN,11.68,11.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUOROURACIL 1000 MG/20 ML IN,2500032365,CDM,636,RC,J9190,HCPCS,1672927667,NDC,,,,inpatient,facility,20,UN,94.68,94.68,7.57,94.68,,,,,,,,,,,,,,94.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.68,,,percent of total billed charges,,,,,,,,,94.68,,,percent of total billed charges,,,48.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.81,,,percent of total billed charges,,,,,,,,,,,,,,,94.68,,,percent of total billed charges,,,80.48,,,percent of total billed charges,,,,,,,,,,,,,,,94.68,,,percent of total billed charges,,,50.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,94.68,,,percent of total billed charges,,,,,,,,,,,,,,,7.57,,,percent of total billed charges,,,94.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.79,,,percent of total billed charges,,
FLUOROURACIL 1000 MG/20 ML IN,2500032365,CDM,636,RC,J9190,HCPCS,1672927667,NDC,,,,outpatient,facility,20,UN,94.68,94.68,1.66,548.68,,2.95,,,fee schedule,,,23.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,94.68,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,94.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,34.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.66,,,fee schedule,,,94.68,,,fee schedule,,,94.68,,,percent of total billed charges,,,,,,,,,94.68,,,percent of total billed charges,,,58.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,55.86,,,percent of total billed charges,,,548.68,,,per diem,,,94.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,94.68,,,percent of total billed charges,,,80.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.28,,,percent of total billed charges,,,94.68,,,percent of total billed charges,,,94.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.87,,,percent of total billed charges,,,76.62,,,percent of total billed charges,,,,,,,,,,,,,,,37.87,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,94.68,,,percent of total billed charges,,,94.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,94.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.57,,,percent of total billed charges,,,94.68,,,percent of total billed charges,,,,,,,,,,,,,,,94.68,,,percent of total billed charges,,,94.68,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,3.34,,,fee schedule,,,94.68,,,percent of total billed charges,,,94.68,,,percent of total billed charges,,,94.68,,,percent of total billed charges,,,,,,,,,66.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,55.79,,,percent of total billed charges,,
FLUOROURACIL 1000 MG/20 ML IN,2500032365,CDM,636,RC,J9190,HCPCS,1672927667,NDC,495,EAPG,,outpatient,facility,20,UN,94.68,94.68,21.18,31.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.98,,,fee schedule,,,21.18,,,fee schedule,,,28.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,21.18,,,fee schedule,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,21.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FLUORESCEIN SODIUM 0.6 MG OPHT,2500032366,CDM,637,RC,1747840303,NDC,,,,,,inpatient,facility,0.6,UN,0.5,0.5,0.04,0.5,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,0.5,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.3,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.29,,,percent of total billed charges,,
FLUORESCEIN SODIUM 0.6 MG OPHT,2500032366,CDM,637,RC,1747840303,NDC,,,,,,outpatient,facility,0.6,UN,0.5,0.5,0.04,548.68,,0.35,,,percent of total billed charges,,,0.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.5,,,percent of total billed charges,,,0.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.5,,,fee schedule,,,0.5,,,percent of total billed charges,,,,,,,,,0.5,,,percent of total billed charges,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,0.3,,,percent of total billed charges,,,548.68,,,per diem,,,0.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.5,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.2,,,percent of total billed charges,,,,,,,,,0.18,,,percent of total billed charges,,,0.18,,,percent of total billed charges,,,,,,,,,0.5,,,percent of total billed charges,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,0.47,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,0.5,,,percent of total billed charges,,,,,,,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.29,,,percent of total billed charges,,
FLUORESCEIN SODIUM 0.6 MG OPHT,2500032366,CDM,637,RC,1747840303,NDC,999,EAPG,,,,outpatient,facility,0.6,UN,0.5,0.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
hydroCHLOROthiazide 12.5MG TAB,2500032369,CDM,637,RC,6068768301,NDC,,,,,,inpatient,facility,12.5,UN,0.46,0.46,0.04,0.46,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.04,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.27,,,percent of total billed charges,,
hydroCHLOROthiazide 12.5MG TAB,2500032369,CDM,637,RC,6068768301,NDC,,,,,,outpatient,facility,12.5,UN,0.46,0.46,0.04,548.68,,0.33,,,percent of total billed charges,,,0.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.46,,,percent of total billed charges,,,0.29,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.32,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.17,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.46,,,fee schedule,,,0.46,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.25,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,0.25,,,percent of total billed charges,,,,,,,,,0.27,,,percent of total billed charges,,,548.68,,,per diem,,,0.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.46,,,percent of total billed charges,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.24,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.31,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.18,,,percent of total billed charges,,,,,,,,,0.17,,,percent of total billed charges,,,0.17,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.04,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,0.43,,,percent of total billed charges,,,,,,,,,,,,,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.43,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,0.46,,,percent of total billed charges,,,,,,,,,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.23,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.27,,,percent of total billed charges,,
hydroCHLOROthiazide 12.5MG TAB,2500032369,CDM,637,RC,6068768301,NDC,999,EAPG,,,,outpatient,facility,12.5,UN,0.46,0.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HEMORRHOIDAL PREP CREAM 26 GM,2500032370,CDM,637,RC,573286893,NDC,,,,,,inpatient,facility,26,UN,15.44,15.44,1.24,15.44,,,,,,,,,,,,,,15.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.44,,,percent of total billed charges,,,,,,,,,15.44,,,percent of total billed charges,,,7.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.26,,,percent of total billed charges,,,,,,,,,,,,,,,15.44,,,percent of total billed charges,,,13.12,,,percent of total billed charges,,,,,,,,,,,,,,,15.44,,,percent of total billed charges,,,8.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,15.44,,,percent of total billed charges,,,,,,,,,,,,,,,1.24,,,percent of total billed charges,,,15.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.1,,,percent of total billed charges,,
HEMORRHOIDAL PREP CREAM 26 GM,2500032370,CDM,637,RC,573286893,NDC,,,,,,outpatient,facility,26,UN,15.44,15.44,1.24,548.68,,10.95,,,percent of total billed charges,,,3.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,15.44,,,percent of total billed charges,,,9.68,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,10.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,10.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,15.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,15.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,15.44,,,fee schedule,,,15.44,,,percent of total billed charges,,,,,,,,,15.44,,,percent of total billed charges,,,9.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11,,,percent of total billed charges,,,,,,,,,,,,,,,8.34,,,percent of total billed charges,,,8.03,,,percent of total billed charges,,,8.49,,,percent of total billed charges,,,,,,,,,9.11,,,percent of total billed charges,,,548.68,,,per diem,,,15.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,15.44,,,percent of total billed charges,,,13.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.2,,,percent of total billed charges,,,15.44,,,percent of total billed charges,,,15.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.42,,,percent of total billed charges,,,12.49,,,percent of total billed charges,,,,,,,,,,,,,,,6.18,,,percent of total billed charges,,,,,,,,,5.71,,,percent of total billed charges,,,5.71,,,percent of total billed charges,,,,,,,,,15.44,,,percent of total billed charges,,,15.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.24,,,percent of total billed charges,,,15.44,,,percent of total billed charges,,,,,,,,,,,,,,,15.44,,,percent of total billed charges,,,15.44,,,percent of total billed charges,,,,,,,,,14.36,,,percent of total billed charges,,,,,,,,,,,,,,,14.36,,,percent of total billed charges,,,14.36,,,percent of total billed charges,,,14.36,,,percent of total billed charges,,,11.58,,,percent of total billed charges,,,15.44,,,percent of total billed charges,,,15.44,,,percent of total billed charges,,,15.44,,,percent of total billed charges,,,,,,,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,9.1,,,percent of total billed charges,,
HEMORRHOIDAL PREP CREAM 26 GM,2500032370,CDM,637,RC,573286893,NDC,999,EAPG,,,,outpatient,facility,26,UN,15.44,15.44,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POTASSIUM CHLORIDE 10 MEQ TABC,2500032374,CDM,637,RC,245531701,NDC,,,,,,inpatient,facility,10,UN,2.04,2.04,0.16,2.04,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.22,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,1.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,
POTASSIUM CHLORIDE 10 MEQ TABC,2500032374,CDM,637,RC,245531701,NDC,,,,,,outpatient,facility,10,UN,2.04,2.04,0.16,548.68,,1.45,,,percent of total billed charges,,,0.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2.04,,,percent of total billed charges,,,1.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.75,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2.04,,,fee schedule,,,2.04,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.45,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,1.12,,,percent of total billed charges,,,,,,,,,1.2,,,percent of total billed charges,,,548.68,,,per diem,,,2.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2.04,,,percent of total billed charges,,,1.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.38,,,percent of total billed charges,,,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,0.75,,,percent of total billed charges,,,0.75,,,percent of total billed charges,,,,,,,,,2.04,,,percent of total billed charges,,,2.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,1.9,,,percent of total billed charges,,,,,,,,,,,,,,,1.9,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,1.9,,,percent of total billed charges,,,1.53,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,2.04,,,percent of total billed charges,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.2,,,percent of total billed charges,,
POTASSIUM CHLORIDE 10 MEQ TABC,2500032374,CDM,637,RC,245531701,NDC,999,EAPG,,,,outpatient,facility,10,UN,2.04,2.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE/EPI/TETRACAINE KIT,2500032375,CDM,637,RC,6229550133,NDC,,,,,,inpatient,facility,1,UN,0.69,0.69,0.06,0.69,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,0.06,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,
LIDOCAINE/EPI/TETRACAINE KIT,2500032375,CDM,637,RC,6229550133,NDC,,,,,,outpatient,facility,1,UN,0.69,0.69,0.06,548.68,,0.49,,,percent of total billed charges,,,0.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.69,,,percent of total billed charges,,,0.43,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.49,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.69,,,fee schedule,,,0.69,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,0.38,,,percent of total billed charges,,,,,,,,,0.41,,,percent of total billed charges,,,548.68,,,per diem,,,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.69,,,percent of total billed charges,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.37,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.28,,,percent of total billed charges,,,,,,,,,0.26,,,percent of total billed charges,,,0.26,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.06,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.64,,,percent of total billed charges,,,0.52,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,0.69,,,percent of total billed charges,,,,,,,,,0.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.41,,,percent of total billed charges,,
LIDOCAINE/EPI/TETRACAINE KIT,2500032375,CDM,637,RC,6229550133,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.69,0.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MIDAZOLAM/NS 50 MG/50 ML BAG,2500032380,CDM,636,RC,J2250,HCPCS,4778158991,NDC,,,,inpatient,facility,50,UN,116.82,116.82,9.35,116.82,,,,,,,,,,,,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.82,,,percent of total billed charges,,,,,,,,,116.82,,,percent of total billed charges,,,59.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.09,,,percent of total billed charges,,,,,,,,,,,,,,,116.82,,,percent of total billed charges,,,99.3,,,percent of total billed charges,,,,,,,,,,,,,,,116.82,,,percent of total billed charges,,,62.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,,9.35,,,percent of total billed charges,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.83,,,percent of total billed charges,,
MIDAZOLAM/NS 50 MG/50 ML BAG,2500032380,CDM,636,RC,J2250,HCPCS,4778158991,NDC,,,,outpatient,facility,50,UN,116.82,116.82,0.08,548.68,,82.84,,,percent of total billed charges,,,28.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,116.82,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,42.76,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.08,,,fee schedule,,,116.82,,,fee schedule,,,116.82,,,percent of total billed charges,,,,,,,,,116.82,,,percent of total billed charges,,,71.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,68.92,,,percent of total billed charges,,,548.68,,,per diem,,,116.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,116.82,,,percent of total billed charges,,,99.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.04,,,percent of total billed charges,,,116.82,,,percent of total billed charges,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.81,,,percent of total billed charges,,,94.53,,,percent of total billed charges,,,,,,,,,,,,,,,46.73,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,116.82,,,percent of total billed charges,,,116.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,116.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.35,,,percent of total billed charges,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,,116.82,,,percent of total billed charges,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.14,,,fee schedule,,,116.82,,,percent of total billed charges,,,116.82,,,percent of total billed charges,,,116.82,,,percent of total billed charges,,,,,,,,,81.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.41,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,68.83,,,percent of total billed charges,,
MIDAZOLAM/NS 50 MG/50 ML BAG,2500032380,CDM,636,RC,J2250,HCPCS,4778158991,NDC,496,EAPG,,outpatient,facility,50,UN,116.82,116.82,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MIRTAZAPINE ORAL DIS 15MG TAB,2500032381,CDM,637,RC,6586202106,NDC,,,,,,inpatient,facility,15,UN,7.79,7.79,0.62,7.79,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,,,,,,,7.79,,,percent of total billed charges,,,3.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.67,,,percent of total billed charges,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,6.62,,,percent of total billed charges,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,4.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,
MIRTAZAPINE ORAL DIS 15MG TAB,2500032381,CDM,637,RC,6586202106,NDC,,,,,,outpatient,facility,15,UN,7.79,7.79,0.62,548.68,,5.52,,,percent of total billed charges,,,1.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,7.79,,,percent of total billed charges,,,4.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,5.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,5.48,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.85,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7.79,,,fee schedule,,,7.79,,,percent of total billed charges,,,,,,,,,7.79,,,percent of total billed charges,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.55,,,percent of total billed charges,,,,,,,,,,,,,,,4.21,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,4.28,,,percent of total billed charges,,,,,,,,,4.6,,,percent of total billed charges,,,548.68,,,per diem,,,7.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7.79,,,percent of total billed charges,,,6.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4.14,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.26,,,percent of total billed charges,,,6.3,,,percent of total billed charges,,,,,,,,,,,,,,,3.12,,,percent of total billed charges,,,,,,,,,2.88,,,percent of total billed charges,,,2.88,,,percent of total billed charges,,,,,,,,,7.79,,,percent of total billed charges,,,7.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.62,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,7.79,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,7.25,,,percent of total billed charges,,,,,,,,,,,,,,,7.25,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,7.25,,,percent of total billed charges,,,5.84,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,5.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.9,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.59,,,percent of total billed charges,,
MIRTAZAPINE ORAL DIS 15MG TAB,2500032381,CDM,637,RC,6586202106,NDC,999,EAPG,,,,outpatient,facility,15,UN,7.79,7.79,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NITROFURANTOIN SUSP 5 MG/ML UD,2500032389,CDM,637,RC,7019900632,NDC,,,,,,inpatient,facility,1,UN,48.21,48.21,3.86,48.21,,,,,,,,,,,,,,48.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.21,,,percent of total billed charges,,,,,,,,,48.21,,,percent of total billed charges,,,24.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.93,,,percent of total billed charges,,,,,,,,,,,,,,,48.21,,,percent of total billed charges,,,40.98,,,percent of total billed charges,,,,,,,,,,,,,,,48.21,,,percent of total billed charges,,,25.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,48.21,,,percent of total billed charges,,,,,,,,,,,,,,,3.86,,,percent of total billed charges,,,48.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.41,,,percent of total billed charges,,
NITROFURANTOIN SUSP 5 MG/ML UD,2500032389,CDM,637,RC,7019900632,NDC,,,,,,outpatient,facility,1,UN,48.21,48.21,3.86,548.68,,34.19,,,percent of total billed charges,,,11.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,48.21,,,percent of total billed charges,,,30.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,33.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,33.89,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,48.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,17.64,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,48.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,48.21,,,fee schedule,,,48.21,,,percent of total billed charges,,,,,,,,,48.21,,,percent of total billed charges,,,29.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.35,,,percent of total billed charges,,,,,,,,,,,,,,,26.03,,,percent of total billed charges,,,25.07,,,percent of total billed charges,,,26.52,,,percent of total billed charges,,,,,,,,,28.44,,,percent of total billed charges,,,548.68,,,per diem,,,48.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,48.21,,,percent of total billed charges,,,40.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.6,,,percent of total billed charges,,,48.21,,,percent of total billed charges,,,48.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.52,,,percent of total billed charges,,,39.01,,,percent of total billed charges,,,,,,,,,,,,,,,19.28,,,percent of total billed charges,,,,,,,,,17.84,,,percent of total billed charges,,,17.84,,,percent of total billed charges,,,,,,,,,48.21,,,percent of total billed charges,,,48.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,48.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,3.86,,,percent of total billed charges,,,48.21,,,percent of total billed charges,,,,,,,,,,,,,,,48.21,,,percent of total billed charges,,,48.21,,,percent of total billed charges,,,,,,,,,44.84,,,percent of total billed charges,,,,,,,,,,,,,,,44.84,,,percent of total billed charges,,,44.84,,,percent of total billed charges,,,44.84,,,percent of total billed charges,,,36.16,,,percent of total billed charges,,,48.21,,,percent of total billed charges,,,48.21,,,percent of total billed charges,,,48.21,,,percent of total billed charges,,,,,,,,,33.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.11,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,28.41,,,percent of total billed charges,,
NITROFURANTOIN SUSP 5 MG/ML UD,2500032389,CDM,637,RC,7019900632,NDC,999,EAPG,,,,outpatient,facility,1,UN,48.21,48.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NOREPINEPHRINE/NS 16 MG/250 ML,2500032390,CDM,250,RC,4456764201,NDC,,,,,,inpatient,facility,250,UN,229.32,229.32,18.35,229.32,,,,,,,,,,,,,,229.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,229.32,,,percent of total billed charges,,,,,,,,,229.32,,,percent of total billed charges,,,117.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.59,,,percent of total billed charges,,,,,,,,,,,,,,,229.32,,,percent of total billed charges,,,194.92,,,percent of total billed charges,,,,,,,,,,,,,,,229.32,,,percent of total billed charges,,,121.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,229.32,,,percent of total billed charges,,,,,,,,,,,,,,,18.35,,,percent of total billed charges,,,229.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,229.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.12,,,percent of total billed charges,,
NOREPINEPHRINE/NS 16 MG/250 ML,2500032390,CDM,250,RC,4456764201,NDC,,,,,,outpatient,facility,250,UN,229.32,229.32,18.35,548.68,,162.61,,,percent of total billed charges,,,55.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,229.32,,,percent of total billed charges,,,143.71,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,161.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,161.21,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,229.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,83.93,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,229.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,229.32,,,fee schedule,,,229.32,,,percent of total billed charges,,,,,,,,,229.32,,,percent of total billed charges,,,140.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,135.3,,,percent of total billed charges,,,548.68,,,per diem,,,229.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,229.32,,,percent of total billed charges,,,194.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,121.79,,,percent of total billed charges,,,229.32,,,percent of total billed charges,,,229.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.7,,,percent of total billed charges,,,185.57,,,percent of total billed charges,,,,,,,,,,,,,,,91.73,,,percent of total billed charges,,,,,,,,,91.73,,,percent of total billed charges,,,91.73,,,percent of total billed charges,,,,,,,,,229.32,,,percent of total billed charges,,,229.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,229.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.35,,,percent of total billed charges,,,229.32,,,percent of total billed charges,,,,,,,,,,,,,,,229.32,,,percent of total billed charges,,,229.32,,,percent of total billed charges,,,,,,,,,91.73,,,percent of total billed charges,,,,,,,,,,,,,,,91.73,,,percent of total billed charges,,,91.73,,,percent of total billed charges,,,91.73,,,percent of total billed charges,,,171.99,,,percent of total billed charges,,,229.32,,,percent of total billed charges,,,229.32,,,percent of total billed charges,,,229.32,,,percent of total billed charges,,,,,,,,,160.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,135.12,,,percent of total billed charges,,
NOREPINEPHRINE/NS 16 MG/250 ML,2500032390,CDM,250,RC,4456764201,NDC,999,EAPG,,,,outpatient,facility,250,UN,229.32,229.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NOREPINEPHRINE/NS 32 MG/250 ML,2500032391,CDM,250,RC,7032470201,NDC,,,,,,inpatient,facility,250,UN,231,231,18.48,231,,,,,,,,,,,,,,231,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231,,,percent of total billed charges,,,,,,,,,231,,,percent of total billed charges,,,117.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.6,,,percent of total billed charges,,,,,,,,,,,,,,,231,,,percent of total billed charges,,,196.35,,,percent of total billed charges,,,,,,,,,,,,,,,231,,,percent of total billed charges,,,122.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,231,,,percent of total billed charges,,,,,,,,,,,,,,,18.48,,,percent of total billed charges,,,231,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,231,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.11,,,percent of total billed charges,,
NOREPINEPHRINE/NS 32 MG/250 ML,2500032391,CDM,250,RC,7032470201,NDC,,,,,,outpatient,facility,250,UN,231,231,18.48,548.68,,163.8,,,percent of total billed charges,,,56.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,231,,,percent of total billed charges,,,144.77,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,162.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,162.39,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,231,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,84.55,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,231,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,231,,,fee schedule,,,231,,,percent of total billed charges,,,,,,,,,231,,,percent of total billed charges,,,141.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,136.29,,,percent of total billed charges,,,548.68,,,per diem,,,231,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,231,,,percent of total billed charges,,,196.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,122.68,,,percent of total billed charges,,,231,,,percent of total billed charges,,,231,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.83,,,percent of total billed charges,,,186.93,,,percent of total billed charges,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,,,,,92.4,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,,,,,,,231,,,percent of total billed charges,,,231,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,231,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.48,,,percent of total billed charges,,,231,,,percent of total billed charges,,,,,,,,,,,,,,,231,,,percent of total billed charges,,,231,,,percent of total billed charges,,,,,,,,,92.4,,,percent of total billed charges,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,92.4,,,percent of total billed charges,,,173.25,,,percent of total billed charges,,,231,,,percent of total billed charges,,,231,,,percent of total billed charges,,,231,,,percent of total billed charges,,,,,,,,,161.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.5,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,136.11,,,percent of total billed charges,,
NOREPINEPHRINE/NS 32 MG/250 ML,2500032391,CDM,250,RC,7032470201,NDC,999,EAPG,,,,outpatient,facility,250,UN,231,231,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NACL 7   1 INH/4 ML NEB,2500032392,CDM,250,RC,8349030760,NDC,,,,,,inpatient,facility,4,UN,0.99,0.99,0.08,0.99,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
NACL 7   1 INH/4 ML NEB,2500032392,CDM,250,RC,8349030760,NDC,,,,,,outpatient,facility,4,UN,0.99,0.99,0.08,548.68,,0.7,,,percent of total billed charges,,,0.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.99,,,percent of total billed charges,,,0.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.99,,,fee schedule,,,0.99,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,0.58,,,percent of total billed charges,,,548.68,,,per diem,,,0.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.99,,,percent of total billed charges,,,0.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.53,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.67,,,percent of total billed charges,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.08,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,,,,,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,0.99,,,percent of total billed charges,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.58,,,percent of total billed charges,,
NACL 7   1 INH/4 ML NEB,2500032392,CDM,250,RC,8349030760,NDC,999,EAPG,,,,outpatient,facility,4,UN,0.99,0.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PALIPERIDONE 1.5 MG TABER,2500032394,CDM,637,RC,6516228003,NDC,,,,,,inpatient,facility,1.5,UN,100.98,100.98,8.08,100.98,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,,,,,,,100.98,,,percent of total billed charges,,,51.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.59,,,percent of total billed charges,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,85.83,,,percent of total billed charges,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,53.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,8.08,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.5,,,percent of total billed charges,,
PALIPERIDONE 1.5 MG TABER,2500032394,CDM,637,RC,6516228003,NDC,,,,,,outpatient,facility,1.5,UN,100.98,100.98,8.08,548.68,,71.6,,,percent of total billed charges,,,24.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,100.98,,,percent of total billed charges,,,63.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,70.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,70.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,36.96,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,100.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,100.98,,,fee schedule,,,100.98,,,percent of total billed charges,,,,,,,,,100.98,,,percent of total billed charges,,,61.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.95,,,percent of total billed charges,,,,,,,,,,,,,,,54.53,,,percent of total billed charges,,,52.51,,,percent of total billed charges,,,55.54,,,percent of total billed charges,,,,,,,,,59.58,,,percent of total billed charges,,,548.68,,,per diem,,,100.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,100.98,,,percent of total billed charges,,,85.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.63,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.12,,,percent of total billed charges,,,81.71,,,percent of total billed charges,,,,,,,,,,,,,,,40.39,,,percent of total billed charges,,,,,,,,,37.36,,,percent of total billed charges,,,37.36,,,percent of total billed charges,,,,,,,,,100.98,,,percent of total billed charges,,,100.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,100.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.08,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,,,,,,,,,,,,,100.98,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,,,,,,,93.93,,,percent of total billed charges,,,,,,,,,,,,,,,93.93,,,percent of total billed charges,,,93.93,,,percent of total billed charges,,,93.93,,,percent of total billed charges,,,75.73,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,,,,,,,70.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,59.5,,,percent of total billed charges,,
PALIPERIDONE 1.5 MG TABER,2500032394,CDM,637,RC,6516228003,NDC,999,EAPG,,,,outpatient,facility,1.5,UN,100.98,100.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMYLASE/LIPASE/PROTEASE 12000,2500032395,CDM,637,RC,32004770,NDC,,,,,,inpatient,facility,12000,UN,13.69,13.69,1.1,13.69,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,13.69,,,percent of total billed charges,,,6.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.21,,,percent of total billed charges,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,11.64,,,percent of total billed charges,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,7.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,1.1,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.07,,,percent of total billed charges,,
AMYLASE/LIPASE/PROTEASE 12000,2500032395,CDM,637,RC,32004770,NDC,,,,,,outpatient,facility,12000,UN,13.69,13.69,1.1,548.68,,9.71,,,percent of total billed charges,,,3.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,13.69,,,percent of total billed charges,,,8.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13.69,,,fee schedule,,,13.69,,,percent of total billed charges,,,,,,,,,13.69,,,percent of total billed charges,,,8.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.75,,,percent of total billed charges,,,,,,,,,,,,,,,7.39,,,percent of total billed charges,,,7.12,,,percent of total billed charges,,,7.53,,,percent of total billed charges,,,,,,,,,8.08,,,percent of total billed charges,,,548.68,,,per diem,,,13.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13.69,,,percent of total billed charges,,,11.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.27,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.24,,,percent of total billed charges,,,11.08,,,percent of total billed charges,,,,,,,,,,,,,,,5.48,,,percent of total billed charges,,,,,,,,,5.07,,,percent of total billed charges,,,5.07,,,percent of total billed charges,,,,,,,,,13.69,,,percent of total billed charges,,,13.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.1,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,,,,,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,12.73,,,percent of total billed charges,,,,,,,,,,,,,,,12.73,,,percent of total billed charges,,,12.73,,,percent of total billed charges,,,12.73,,,percent of total billed charges,,,10.27,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,13.69,,,percent of total billed charges,,,,,,,,,9.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.84,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.07,,,percent of total billed charges,,
AMYLASE/LIPASE/PROTEASE 12000,2500032395,CDM,637,RC,32004770,NDC,999,EAPG,,,,outpatient,facility,12000,UN,13.69,13.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMYLASE/LIPASE/PROTEASE 6000,2500032397,CDM,637,RC,32004670,NDC,,,,,,inpatient,facility,6000,UN,6.86,6.86,0.55,6.86,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,6.86,,,percent of total billed charges,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,5.83,,,percent of total billed charges,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,3.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,
AMYLASE/LIPASE/PROTEASE 6000,2500032397,CDM,637,RC,32004670,NDC,,,,,,outpatient,facility,6000,UN,6.86,6.86,0.55,548.68,,4.86,,,percent of total billed charges,,,1.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,6.86,,,percent of total billed charges,,,4.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,4.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,4.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,2.51,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6.86,,,fee schedule,,,6.86,,,percent of total billed charges,,,,,,,,,6.86,,,percent of total billed charges,,,4.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,,,,,,,,,,,,,3.7,,,percent of total billed charges,,,3.57,,,percent of total billed charges,,,3.77,,,percent of total billed charges,,,,,,,,,4.05,,,percent of total billed charges,,,548.68,,,per diem,,,6.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6.86,,,percent of total billed charges,,,5.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3.64,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.63,,,percent of total billed charges,,,5.55,,,percent of total billed charges,,,,,,,,,,,,,,,2.74,,,percent of total billed charges,,,,,,,,,2.54,,,percent of total billed charges,,,2.54,,,percent of total billed charges,,,,,,,,,6.86,,,percent of total billed charges,,,6.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,6.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.55,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,,,,,,,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,6.38,,,percent of total billed charges,,,,,,,,,,,,,,,6.38,,,percent of total billed charges,,,6.38,,,percent of total billed charges,,,6.38,,,percent of total billed charges,,,5.15,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,6.86,,,percent of total billed charges,,,,,,,,,4.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4.04,,,percent of total billed charges,,
AMYLASE/LIPASE/PROTEASE 6000,2500032397,CDM,637,RC,32004670,NDC,999,EAPG,,,,outpatient,facility,6000,UN,6.86,6.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PETROLATUMWHITE 16.8 GM TUBE,2500032398,CDM,637,RC,8884430100,NDC,,,,,,inpatient,facility,16.8,UN,2,2,0.16,2,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
PETROLATUMWHITE 16.8 GM TUBE,2500032398,CDM,637,RC,8884430100,NDC,,,,,,outpatient,facility,16.8,UN,2,2,0.16,548.68,,1.42,,,percent of total billed charges,,,0.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,2,,,percent of total billed charges,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.73,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2,,,fee schedule,,,2,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,1.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.08,,,percent of total billed charges,,,1.04,,,percent of total billed charges,,,1.1,,,percent of total billed charges,,,,,,,,,1.18,,,percent of total billed charges,,,548.68,,,per diem,,,2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2,,,percent of total billed charges,,,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.06,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.35,,,percent of total billed charges,,,1.62,,,percent of total billed charges,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,,,,0.74,,,percent of total billed charges,,,0.74,,,percent of total billed charges,,,,,,,,,2,,,percent of total billed charges,,,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.16,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.86,,,percent of total billed charges,,,,,,,,,,,,,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.86,,,percent of total billed charges,,,1.5,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,2,,,percent of total billed charges,,,,,,,,,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.18,,,percent of total billed charges,,
PETROLATUMWHITE 16.8 GM TUBE,2500032398,CDM,637,RC,8884430100,NDC,999,EAPG,,,,outpatient,facility,16.8,UN,2,2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TIOTROPIUM/OLODATEROL 4 GM INH,2500032407,CDM,637,RC,597015570,NDC,,,,,,inpatient,facility,4,UN,247.5,247.5,19.8,247.5,,,,,,,,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,247.5,,,percent of total billed charges,,,126.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,,,,,,,247.5,,,percent of total billed charges,,,210.38,,,percent of total billed charges,,,,,,,,,,,,,,,247.5,,,percent of total billed charges,,,131.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,19.8,,,percent of total billed charges,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.83,,,percent of total billed charges,,
TIOTROPIUM/OLODATEROL 4 GM INH,2500032407,CDM,637,RC,597015570,NDC,,,,,,outpatient,facility,4,UN,247.5,247.5,19.8,548.68,,175.5,,,percent of total billed charges,,,60.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,247.5,,,percent of total billed charges,,,155.11,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,173.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,173.99,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,90.58,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,247.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,247.5,,,fee schedule,,,247.5,,,percent of total billed charges,,,,,,,,,247.5,,,percent of total billed charges,,,151.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.34,,,percent of total billed charges,,,,,,,,,,,,,,,133.65,,,percent of total billed charges,,,128.7,,,percent of total billed charges,,,136.13,,,percent of total billed charges,,,,,,,,,146.02,,,percent of total billed charges,,,548.68,,,per diem,,,247.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,247.5,,,percent of total billed charges,,,210.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,131.45,,,percent of total billed charges,,,247.5,,,percent of total billed charges,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.96,,,percent of total billed charges,,,200.28,,,percent of total billed charges,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,91.58,,,percent of total billed charges,,,91.58,,,percent of total billed charges,,,,,,,,,247.5,,,percent of total billed charges,,,247.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,247.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.8,,,percent of total billed charges,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,247.5,,,percent of total billed charges,,,247.5,,,percent of total billed charges,,,,,,,,,230.22,,,percent of total billed charges,,,,,,,,,,,,,,,230.22,,,percent of total billed charges,,,230.22,,,percent of total billed charges,,,230.22,,,percent of total billed charges,,,185.63,,,percent of total billed charges,,,247.5,,,percent of total billed charges,,,247.5,,,percent of total billed charges,,,247.5,,,percent of total billed charges,,,,,,,,,173.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,145.83,,,percent of total billed charges,,
TIOTROPIUM/OLODATEROL 4 GM INH,2500032407,CDM,637,RC,597015570,NDC,999,EAPG,,,,outpatient,facility,4,UN,247.5,247.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SURGICEL 4 X 8 PAD,2500032408,CDM,250,RC,,,,,,,,inpatient,facility,1,UN,168.2,168.2,13.46,168.2,,,,,,,,,,,,,,168.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.2,,,percent of total billed charges,,,,,,,,,168.2,,,percent of total billed charges,,,85.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.92,,,percent of total billed charges,,,,,,,,,,,,,,,168.2,,,percent of total billed charges,,,142.97,,,percent of total billed charges,,,,,,,,,,,,,,,168.2,,,percent of total billed charges,,,89.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,168.2,,,percent of total billed charges,,,,,,,,,,,,,,,13.46,,,percent of total billed charges,,,168.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,168.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.1,,,percent of total billed charges,,
SURGICEL 4 X 8 PAD,2500032408,CDM,250,RC,,,,,,,,outpatient,facility,1,UN,168.2,168.2,13.46,548.68,,119.27,,,percent of total billed charges,,,41.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,168.2,,,percent of total billed charges,,,105.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,118.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,118.24,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,168.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,61.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,168.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,168.2,,,fee schedule,,,168.2,,,percent of total billed charges,,,,,,,,,168.2,,,percent of total billed charges,,,103.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,99.24,,,percent of total billed charges,,,548.68,,,per diem,,,168.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,168.2,,,percent of total billed charges,,,142.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,89.33,,,percent of total billed charges,,,168.2,,,percent of total billed charges,,,168.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.47,,,percent of total billed charges,,,136.11,,,percent of total billed charges,,,,,,,,,,,,,,,67.28,,,percent of total billed charges,,,,,,,,,67.28,,,percent of total billed charges,,,67.28,,,percent of total billed charges,,,,,,,,,168.2,,,percent of total billed charges,,,168.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,168.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,13.46,,,percent of total billed charges,,,168.2,,,percent of total billed charges,,,,,,,,,,,,,,,168.2,,,percent of total billed charges,,,168.2,,,percent of total billed charges,,,,,,,,,67.28,,,percent of total billed charges,,,,,,,,,,,,,,,67.28,,,percent of total billed charges,,,67.28,,,percent of total billed charges,,,67.28,,,percent of total billed charges,,,126.15,,,percent of total billed charges,,,168.2,,,percent of total billed charges,,,168.2,,,percent of total billed charges,,,168.2,,,percent of total billed charges,,,,,,,,,117.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.1,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,99.1,,,percent of total billed charges,,
SURGICEL 4 X 8 PAD,2500032408,CDM,250,RC,999,EAPG,,,,,,outpatient,facility,1,UN,168.2,168.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
UMECLIDINIUM 62.5 MCG INH,2500032413,CDM,637,RC,173087306,NDC,,,,,,inpatient,facility,1,UN,35.37,35.37,2.83,35.37,,,,,,,,,,,,,,35.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.37,,,percent of total billed charges,,,,,,,,,35.37,,,percent of total billed charges,,,18.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.22,,,percent of total billed charges,,,,,,,,,,,,,,,35.37,,,percent of total billed charges,,,30.06,,,percent of total billed charges,,,,,,,,,,,,,,,35.37,,,percent of total billed charges,,,18.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,35.37,,,percent of total billed charges,,,,,,,,,,,,,,,2.83,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.84,,,percent of total billed charges,,
UMECLIDINIUM 62.5 MCG INH,2500032413,CDM,637,RC,173087306,NDC,,,,,,outpatient,facility,1,UN,35.37,35.37,2.83,548.68,,25.08,,,percent of total billed charges,,,8.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,35.37,,,percent of total billed charges,,,22.17,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,24.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,24.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,35.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.95,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,35.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,35.37,,,fee schedule,,,35.37,,,percent of total billed charges,,,,,,,,,35.37,,,percent of total billed charges,,,21.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.2,,,percent of total billed charges,,,,,,,,,,,,,,,19.1,,,percent of total billed charges,,,18.39,,,percent of total billed charges,,,19.45,,,percent of total billed charges,,,,,,,,,20.87,,,percent of total billed charges,,,548.68,,,per diem,,,35.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,35.37,,,percent of total billed charges,,,30.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.79,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.86,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,,,,13.09,,,percent of total billed charges,,,13.09,,,percent of total billed charges,,,,,,,,,35.37,,,percent of total billed charges,,,35.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.83,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,,,,,,,,,,,,,35.37,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,,,,,,,32.9,,,percent of total billed charges,,,,,,,,,,,,,,,32.9,,,percent of total billed charges,,,32.9,,,percent of total billed charges,,,32.9,,,percent of total billed charges,,,26.53,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,,,,,,,24.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.68,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,20.84,,,percent of total billed charges,,
UMECLIDINIUM 62.5 MCG INH,2500032413,CDM,637,RC,173087306,NDC,999,EAPG,,,,outpatient,facility,1,UN,35.37,35.37,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ACETAZOLAMIDE 500 MG CAPER,2500032419,CDM,637,RC,5074223301,NDC,,,,,,inpatient,facility,500,UN,14.16,14.16,1.13,14.16,,,,,,,,,,,,,,14.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.16,,,percent of total billed charges,,,,,,,,,14.16,,,percent of total billed charges,,,7.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.5,,,percent of total billed charges,,,,,,,,,,,,,,,14.16,,,percent of total billed charges,,,12.04,,,percent of total billed charges,,,,,,,,,,,,,,,14.16,,,percent of total billed charges,,,7.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.16,,,percent of total billed charges,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,,14.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.34,,,percent of total billed charges,,
ACETAZOLAMIDE 500 MG CAPER,2500032419,CDM,637,RC,5074223301,NDC,,,,,,outpatient,facility,500,UN,14.16,14.16,1.13,548.68,,10.04,,,percent of total billed charges,,,3.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.16,,,percent of total billed charges,,,8.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,9.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,9.95,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,14.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,5.18,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,14.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,14.16,,,fee schedule,,,14.16,,,percent of total billed charges,,,,,,,,,14.16,,,percent of total billed charges,,,8.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.09,,,percent of total billed charges,,,,,,,,,,,,,,,7.65,,,percent of total billed charges,,,7.36,,,percent of total billed charges,,,7.79,,,percent of total billed charges,,,,,,,,,8.35,,,percent of total billed charges,,,548.68,,,per diem,,,14.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,14.16,,,percent of total billed charges,,,12.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.52,,,percent of total billed charges,,,14.16,,,percent of total billed charges,,,14.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.55,,,percent of total billed charges,,,11.46,,,percent of total billed charges,,,,,,,,,,,,,,,5.66,,,percent of total billed charges,,,,,,,,,5.24,,,percent of total billed charges,,,5.24,,,percent of total billed charges,,,,,,,,,14.16,,,percent of total billed charges,,,14.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.13,,,percent of total billed charges,,,14.16,,,percent of total billed charges,,,,,,,,,,,,,,,14.16,,,percent of total billed charges,,,14.16,,,percent of total billed charges,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,13.17,,,percent of total billed charges,,,13.17,,,percent of total billed charges,,,13.17,,,percent of total billed charges,,,10.62,,,percent of total billed charges,,,14.16,,,percent of total billed charges,,,14.16,,,percent of total billed charges,,,14.16,,,percent of total billed charges,,,,,,,,,9.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.08,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8.34,,,percent of total billed charges,,
ACETAZOLAMIDE 500 MG CAPER,2500032419,CDM,637,RC,5074223301,NDC,999,EAPG,,,,outpatient,facility,500,UN,14.16,14.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ELEVIEW 10 ML AMP,2500032498,CDM,250,RC,5391530190,NDC,,,,,,inpatient,facility,10,UN,267.3,267.3,21.38,267.3,,,,,,,,,,,,,,267.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.3,,,percent of total billed charges,,,,,,,,,267.3,,,percent of total billed charges,,,136.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.38,,,percent of total billed charges,,,,,,,,,,,,,,,267.3,,,percent of total billed charges,,,227.2,,,percent of total billed charges,,,,,,,,,,,,,,,267.3,,,percent of total billed charges,,,141.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,267.3,,,percent of total billed charges,,,,,,,,,,,,,,,21.38,,,percent of total billed charges,,,267.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.49,,,percent of total billed charges,,
ELEVIEW 10 ML AMP,2500032498,CDM,250,RC,5391530190,NDC,,,,,,outpatient,facility,10,UN,267.3,267.3,21.38,548.68,,189.54,,,percent of total billed charges,,,65.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,267.3,,,percent of total billed charges,,,167.52,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,187.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,187.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,267.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,97.83,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,267.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,267.3,,,fee schedule,,,267.3,,,percent of total billed charges,,,,,,,,,267.3,,,percent of total billed charges,,,163.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,157.71,,,percent of total billed charges,,,548.68,,,per diem,,,267.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,267.3,,,percent of total billed charges,,,227.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,141.96,,,percent of total billed charges,,,267.3,,,percent of total billed charges,,,267.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.32,,,percent of total billed charges,,,216.3,,,percent of total billed charges,,,,,,,,,,,,,,,106.92,,,percent of total billed charges,,,,,,,,,106.92,,,percent of total billed charges,,,106.92,,,percent of total billed charges,,,,,,,,,267.3,,,percent of total billed charges,,,267.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,267.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,21.38,,,percent of total billed charges,,,267.3,,,percent of total billed charges,,,,,,,,,,,,,,,267.3,,,percent of total billed charges,,,267.3,,,percent of total billed charges,,,,,,,,,106.92,,,percent of total billed charges,,,,,,,,,,,,,,,106.92,,,percent of total billed charges,,,106.92,,,percent of total billed charges,,,106.92,,,percent of total billed charges,,,200.48,,,percent of total billed charges,,,267.3,,,percent of total billed charges,,,267.3,,,percent of total billed charges,,,267.3,,,percent of total billed charges,,,,,,,,,187.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.65,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,157.49,,,percent of total billed charges,,
ELEVIEW 10 ML AMP,2500032498,CDM,250,RC,5391530190,NDC,999,EAPG,,,,outpatient,facility,10,UN,267.3,267.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INFLIXIMAB-DYYB INJ 100 MG,2500032499,CDM,636,RC,Q5103,HCPCS,69080901,NDC,,,,inpatient,facility,100,GR,3122.72,3122.72,249.82,3122.72,,,,,,,,,,,,,,3122.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3122.72,,,percent of total billed charges,,,,,,,,,3122.72,,,percent of total billed charges,,,1594.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2659.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1873.63,,,percent of total billed charges,,,,,,,,,,,,,,,3122.72,,,percent of total billed charges,,,2654.31,,,percent of total billed charges,,,,,,,,,,,,,,,3122.72,,,percent of total billed charges,,,1658.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1249.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3122.72,,,percent of total billed charges,,,,,,,,,,,,,,,249.82,,,percent of total billed charges,,,3122.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3122.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1839.91,,,percent of total billed charges,,
INFLIXIMAB-DYYB INJ 100 MG,2500032499,CDM,636,RC,Q5103,HCPCS,69080901,NDC,,,,outpatient,facility,100,GR,3122.72,3122.72,11.07,3122.72,,2214.32,,,percent of total billed charges,,,,,,,,,3122.72,,,percent of total billed charges,,,13.84,,,fee schedule,,,13.09,,,fee schedule,,,,,,,,,13.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3122.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3122.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3122.72,,,fee schedule,,,3122.72,,,percent of total billed charges,,,,,,,,,3122.72,,,percent of total billed charges,,,1913.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2224.94,,,percent of total billed charges,,,,,,,,,,,,,,,14.29,,,fee schedule,,,14.29,,,fee schedule,,,14.29,,,fee schedule,,,,,,,,,1842.4,,,percent of total billed charges,,,548.68,,,per diem,,,3122.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3122.72,,,percent of total billed charges,,,2654.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1658.48,,,percent of total billed charges,,,3122.72,,,percent of total billed charges,,,3122.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2106.59,,,percent of total billed charges,,,2526.91,,,percent of total billed charges,,,,,,,,,,,,,,,1249.09,,,percent of total billed charges,,,,,,,,,76.04,,,fee schedule,,,54.72,,,fee schedule,,,,,,,,,3122.72,,,percent of total billed charges,,,,,,,,,,,,,,,249.82,,,percent of total billed charges,,,3122.72,,,percent of total billed charges,,,,,,,,,,,,,,,3122.72,,,percent of total billed charges,,,3122.72,,,percent of total billed charges,,,,,,,,,32.5,,,fee schedule,,,,,,,,,,,,,,,28.16,,,fee schedule,,,37.55,,,fee schedule,,,21.13,,,fee schedule,,,11.07,,,fee schedule,,,3122.72,,,percent of total billed charges,,,3122.72,,,percent of total billed charges,,,3122.72,,,percent of total billed charges,,,,,,,,,2189.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1561.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1839.91,,,percent of total billed charges,,
INFLIXIMAB-DYYB INJ 100 MG,2500032499,CDM,636,RC,Q5103,HCPCS,69080901,NDC,1847,APC,,outpatient,facility,100,GR,3122.72,3122.72,11.09,1142.92,,,,,,,,11.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,11.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.67,,,fee schedule,,,,,,,,,1142.92,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,fee schedule,,,,,,,,,,,,,,,12.13,,,fee schedule,,,12.13,,,fee schedule,,,,,,,,,11.55,,,fee schedule,,,11.55,,,fee schedule,,,12.13,,,fee schedule,,,,,,,,,,,,,,,17.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.09,,,fee schedule,,,12.36,,,fee schedule,,,12.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,fee schedule,,,11.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,12.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,fee schedule,,,,,,,,,14.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,11.55,,,fee schedule,,,11.55,,,fee schedule,,,,,,,,,,,,,,,11.55,,,fee schedule,,,,,,,,,11.55,,,fee schedule,,,11.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,fee schedule,,,,,,,,,,,,,,,12.01,,,fee schedule,,,11.55,,,fee schedule,,,,,,,,,11.55,,,fee schedule,,,,,,,,,11.55,,,fee schedule,,,12.13,,,fee schedule,,,,,,,,
INFLIXIMAB-DYYB INJ 100 MG,2500032499,CDM,636,RC,Q5103,HCPCS,69080901,NDC,444,EAPG,,outpatient,facility,100,GR,3122.72,3122.72,1304.36,1969.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1969.58,,,fee schedule,,,1304.36,,,fee schedule,,,1750.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INFLIXIMAB-ABDA INJ 100MG,2500032500,CDM,636,RC,Q5104,HCPCS,7820616201,NDC,,,,inpatient,facility,100,UN,2486.18,2486.18,198.89,2486.18,,,,,,,,,,,,,,2486.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2486.18,,,percent of total billed charges,,,,,,,,,2486.18,,,percent of total billed charges,,,1269.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2117.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1491.71,,,percent of total billed charges,,,,,,,,,,,,,,,2486.18,,,percent of total billed charges,,,2113.25,,,percent of total billed charges,,,,,,,,,,,,,,,2486.18,,,percent of total billed charges,,,1320.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,994.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2486.18,,,percent of total billed charges,,,,,,,,,,,,,,,198.89,,,percent of total billed charges,,,2486.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2486.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1464.86,,,percent of total billed charges,,
INFLIXIMAB-ABDA INJ 100MG,2500032500,CDM,636,RC,Q5104,HCPCS,7820616201,NDC,,,,outpatient,facility,100,UN,2486.18,2486.18,31.04,2486.18,,1762.95,,,percent of total billed charges,,,,,,,,,2486.18,,,percent of total billed charges,,,38.82,,,fee schedule,,,36.73,,,fee schedule,,,,,,,,,36.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2486.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,2486.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,2486.18,,,fee schedule,,,2486.18,,,percent of total billed charges,,,,,,,,,2486.18,,,percent of total billed charges,,,1523.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1771.4,,,percent of total billed charges,,,,,,,,,,,,,,,31.5,,,fee schedule,,,31.5,,,fee schedule,,,31.5,,,fee schedule,,,,,,,,,1466.85,,,percent of total billed charges,,,548.68,,,per diem,,,2486.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2486.18,,,percent of total billed charges,,,2113.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1320.41,,,percent of total billed charges,,,2486.18,,,percent of total billed charges,,,2486.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1677.18,,,percent of total billed charges,,,2011.82,,,percent of total billed charges,,,,,,,,,,,,,,,994.47,,,percent of total billed charges,,,,,,,,,119.53,,,fee schedule,,,86.01,,,fee schedule,,,,,,,,,2486.18,,,percent of total billed charges,,,,,,,,,,,,,,,198.89,,,percent of total billed charges,,,2486.18,,,percent of total billed charges,,,,,,,,,,,,,,,2486.18,,,percent of total billed charges,,,2486.18,,,percent of total billed charges,,,,,,,,,51.08,,,fee schedule,,,,,,,,,,,,,,,44.27,,,fee schedule,,,59.03,,,fee schedule,,,33.2,,,fee schedule,,,31.04,,,fee schedule,,,2486.18,,,percent of total billed charges,,,2486.18,,,percent of total billed charges,,,2486.18,,,percent of total billed charges,,,,,,,,,1743.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1243.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1464.86,,,percent of total billed charges,,
INFLIXIMAB-ABDA INJ 100MG,2500032500,CDM,636,RC,Q5104,HCPCS,7820616201,NDC,9036,APC,,outpatient,facility,100,UN,2486.18,2486.18,25.21,909.94,,,,,,,,27.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,26.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.52,,,fee schedule,,,,,,,,,909.94,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,26.26,,,fee schedule,,,,,,,,,,,,,,,27.57,,,fee schedule,,,27.57,,,fee schedule,,,,,,,,,26.26,,,fee schedule,,,26.26,,,fee schedule,,,27.57,,,fee schedule,,,,,,,,,,,,,,,39.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,26.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.21,,,fee schedule,,,28.1,,,fee schedule,,,27.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.26,,,fee schedule,,,26.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,27.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,26.26,,,fee schedule,,,,,,,,,32.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,32.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,26.26,,,fee schedule,,,26.26,,,fee schedule,,,,,,,,,,,,,,,26.26,,,fee schedule,,,,,,,,,26.26,,,fee schedule,,,27.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.26,,,fee schedule,,,,,,,,,,,,,,,27.31,,,fee schedule,,,26.26,,,fee schedule,,,,,,,,,26.26,,,fee schedule,,,,,,,,,26.26,,,fee schedule,,,27.57,,,fee schedule,,,,,,,,
INFLIXIMAB-ABDA INJ 100MG,2500032500,CDM,636,RC,Q5104,HCPCS,7820616201,NDC,444,EAPG,,outpatient,facility,100,UN,2486.18,2486.18,1304.36,1969.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1969.58,,,fee schedule,,,1304.36,,,fee schedule,,,1750.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MOMETASONE/FORMOT 100/5MCG INH,2500032509,CDM,637,RC,85720607,NDC,,,,,,inpatient,facility,1,UN,695.51,695.51,55.64,695.51,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,,,,,,,695.51,,,percent of total billed charges,,,355.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,417.31,,,percent of total billed charges,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,591.18,,,percent of total billed charges,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,369.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,55.64,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,409.79,,,percent of total billed charges,,
MOMETASONE/FORMOT 100/5MCG INH,2500032509,CDM,637,RC,85720607,NDC,,,,,,outpatient,facility,1,UN,695.51,695.51,55.64,695.51,,493.19,,,percent of total billed charges,,,169.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,695.51,,,percent of total billed charges,,,435.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,488.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,488.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,254.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,695.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,695.51,,,fee schedule,,,695.51,,,percent of total billed charges,,,,,,,,,695.51,,,percent of total billed charges,,,426.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,495.55,,,percent of total billed charges,,,,,,,,,,,,,,,375.58,,,percent of total billed charges,,,361.67,,,percent of total billed charges,,,382.53,,,percent of total billed charges,,,,,,,,,410.35,,,percent of total billed charges,,,548.68,,,per diem,,,695.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,695.51,,,percent of total billed charges,,,591.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,369.39,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,469.19,,,percent of total billed charges,,,562.81,,,percent of total billed charges,,,,,,,,,,,,,,,278.2,,,percent of total billed charges,,,,,,,,,257.34,,,percent of total billed charges,,,257.34,,,percent of total billed charges,,,,,,,,,695.51,,,percent of total billed charges,,,695.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,695.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,55.64,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,,,,,,,646.96,,,percent of total billed charges,,,,,,,,,,,,,,,646.96,,,percent of total billed charges,,,646.96,,,percent of total billed charges,,,646.96,,,percent of total billed charges,,,521.63,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,,,,,,,487.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,347.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,409.79,,,percent of total billed charges,,
MOMETASONE/FORMOT 100/5MCG INH,2500032509,CDM,637,RC,85720607,NDC,999,EAPG,,,,outpatient,facility,1,UN,695.51,695.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MOMETASONE/FORMOT 200/5MCG INH,2500032510,CDM,637,RC,85461005,NDC,,,,,,inpatient,facility,8.8,UN,695.51,695.51,55.64,695.51,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,,,,,,,695.51,,,percent of total billed charges,,,355.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,417.31,,,percent of total billed charges,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,591.18,,,percent of total billed charges,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,369.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,55.64,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,409.79,,,percent of total billed charges,,
MOMETASONE/FORMOT 200/5MCG INH,2500032510,CDM,637,RC,85461005,NDC,,,,,,outpatient,facility,8.8,UN,695.51,695.51,55.64,695.51,,493.19,,,percent of total billed charges,,,169.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,695.51,,,percent of total billed charges,,,435.88,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,488.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,488.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,254.56,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,695.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,695.51,,,fee schedule,,,695.51,,,percent of total billed charges,,,,,,,,,695.51,,,percent of total billed charges,,,426.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,495.55,,,percent of total billed charges,,,,,,,,,,,,,,,375.58,,,percent of total billed charges,,,361.67,,,percent of total billed charges,,,382.53,,,percent of total billed charges,,,,,,,,,410.35,,,percent of total billed charges,,,548.68,,,per diem,,,695.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,695.51,,,percent of total billed charges,,,591.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,369.39,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,469.19,,,percent of total billed charges,,,562.81,,,percent of total billed charges,,,,,,,,,,,,,,,278.2,,,percent of total billed charges,,,,,,,,,257.34,,,percent of total billed charges,,,257.34,,,percent of total billed charges,,,,,,,,,695.51,,,percent of total billed charges,,,695.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,695.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,55.64,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,,,,,,,,,,,,,695.51,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,,,,,,,646.96,,,percent of total billed charges,,,,,,,,,,,,,,,646.96,,,percent of total billed charges,,,646.96,,,percent of total billed charges,,,646.96,,,percent of total billed charges,,,521.63,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,695.51,,,percent of total billed charges,,,,,,,,,487.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,347.75,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,409.79,,,percent of total billed charges,,
MOMETASONE/FORMOT 200/5MCG INH,2500032510,CDM,637,RC,85461005,NDC,999,EAPG,,,,outpatient,facility,8.8,UN,695.51,695.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OBINUTUZUMAB 10 MG/0.4 ML INJ,2500032520,CDM,636,RC,J9301,HCPCS,5024207001,NDC,,,,inpatient,facility,0.4,GR,271.98,271.98,21.76,271.98,,,,,,,,,,,,,,271.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,271.98,,,percent of total billed charges,,,,,,,,,271.98,,,percent of total billed charges,,,138.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.19,,,percent of total billed charges,,,,,,,,,,,,,,,271.98,,,percent of total billed charges,,,231.18,,,percent of total billed charges,,,,,,,,,,,,,,,271.98,,,percent of total billed charges,,,144.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,271.98,,,percent of total billed charges,,,,,,,,,,,,,,,21.76,,,percent of total billed charges,,,271.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,271.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.25,,,percent of total billed charges,,
OBINUTUZUMAB 10 MG/0.4 ML INJ,2500032520,CDM,636,RC,J9301,HCPCS,5024207001,NDC,,,,outpatient,facility,0.4,GR,271.98,271.98,21.76,548.68,,70.22,,,fee schedule,,,,,,,,,271.98,,,percent of total billed charges,,,96.25,,,fee schedule,,,91.06,,,fee schedule,,,,,,,,,91.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,271.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,271.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,271.98,,,fee schedule,,,271.98,,,percent of total billed charges,,,,,,,,,271.98,,,percent of total billed charges,,,166.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.79,,,percent of total billed charges,,,,,,,,,,,,,,,70.34,,,fee schedule,,,70.34,,,fee schedule,,,70.34,,,fee schedule,,,,,,,,,160.47,,,percent of total billed charges,,,548.68,,,per diem,,,271.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,271.98,,,percent of total billed charges,,,231.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,144.45,,,percent of total billed charges,,,271.98,,,percent of total billed charges,,,271.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.48,,,percent of total billed charges,,,220.09,,,percent of total billed charges,,,,,,,,,,,,,,,108.79,,,percent of total billed charges,,,,,,,,,165.48,,,fee schedule,,,119.07,,,fee schedule,,,,,,,,,271.98,,,percent of total billed charges,,,,,,,,,,,,,,,21.76,,,percent of total billed charges,,,271.98,,,percent of total billed charges,,,,,,,,,,,,,,,271.98,,,percent of total billed charges,,,271.98,,,percent of total billed charges,,,,,,,,,70.72,,,fee schedule,,,,,,,,,,,,,,,61.29,,,fee schedule,,,81.72,,,fee schedule,,,45.97,,,fee schedule,,,76.95,,,fee schedule,,,271.98,,,percent of total billed charges,,,271.98,,,percent of total billed charges,,,271.98,,,percent of total billed charges,,,,,,,,,190.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.99,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,160.25,,,percent of total billed charges,,
OBINUTUZUMAB 10 MG/0.4 ML INJ,2500032520,CDM,636,RC,J9301,HCPCS,5024207001,NDC,1476,APC,,outpatient,facility,0.4,GR,271.98,271.98,71.84,112.24,,,,,,,,77.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,74.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.58,,,fee schedule,,,,,,,,,99.54,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,74.83,,,fee schedule,,,,,,,,,,,,,,,78.57,,,fee schedule,,,78.57,,,fee schedule,,,,,,,,,74.83,,,fee schedule,,,74.83,,,fee schedule,,,78.57,,,fee schedule,,,,,,,,,,,,,,,112.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,74.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.84,,,fee schedule,,,80.07,,,fee schedule,,,78.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.83,,,fee schedule,,,74.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,77.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,74.83,,,fee schedule,,,,,,,,,93.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,93.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,74.83,,,fee schedule,,,74.83,,,fee schedule,,,,,,,,,,,,,,,74.83,,,fee schedule,,,,,,,,,74.83,,,fee schedule,,,77.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.83,,,fee schedule,,,,,,,,,,,,,,,77.82,,,fee schedule,,,74.83,,,fee schedule,,,,,,,,,74.83,,,fee schedule,,,,,,,,,74.83,,,fee schedule,,,78.57,,,fee schedule,,,,,,,,
OBINUTUZUMAB 10 MG/0.4 ML INJ,2500032520,CDM,636,RC,J9301,HCPCS,5024207001,NDC,463,EAPG,,outpatient,facility,0.4,GR,271.98,271.98,7053.67,10651.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10651.04,,,fee schedule,,,7053.67,,,fee schedule,,,9468.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
POLYETHYLENE GLYCOL 255 GM BTL,2500032522,CDM,637,RC,536105224,NDC,,,,,,inpatient,facility,255,UN,18.71,18.71,1.5,18.71,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,,,,,,,18.71,,,percent of total billed charges,,,9.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.23,,,percent of total billed charges,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,15.9,,,percent of total billed charges,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,9.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,1.5,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.02,,,percent of total billed charges,,
POLYETHYLENE GLYCOL 255 GM BTL,2500032522,CDM,637,RC,536105224,NDC,,,,,,outpatient,facility,255,UN,18.71,18.71,1.5,548.68,,13.27,,,percent of total billed charges,,,4.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,18.71,,,percent of total billed charges,,,11.73,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,13.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,13.15,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,6.85,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,18.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,18.71,,,fee schedule,,,18.71,,,percent of total billed charges,,,,,,,,,18.71,,,percent of total billed charges,,,11.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.33,,,percent of total billed charges,,,,,,,,,,,,,,,10.1,,,percent of total billed charges,,,9.73,,,percent of total billed charges,,,10.29,,,percent of total billed charges,,,,,,,,,11.04,,,percent of total billed charges,,,548.68,,,per diem,,,18.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,18.71,,,percent of total billed charges,,,15.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.94,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.62,,,percent of total billed charges,,,15.14,,,percent of total billed charges,,,,,,,,,,,,,,,7.48,,,percent of total billed charges,,,,,,,,,6.92,,,percent of total billed charges,,,6.92,,,percent of total billed charges,,,,,,,,,18.71,,,percent of total billed charges,,,18.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,18.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.5,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,,,,,,,,,,,,,18.71,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,14.03,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,18.71,,,percent of total billed charges,,,,,,,,,13.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.36,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.02,,,percent of total billed charges,,
POLYETHYLENE GLYCOL 255 GM BTL,2500032522,CDM,637,RC,536105224,NDC,999,EAPG,,,,outpatient,facility,255,UN,18.71,18.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MULTIVITAMINS LIQ 15 ML UDC,2500032533,CDM,637,RC,5434462,NDC,,,,,,inpatient,facility,15,UN,1.92,1.92,0.15,1.92,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,1.92,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,1.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,0.15,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.13,,,percent of total billed charges,,
MULTIVITAMINS LIQ 15 ML UDC,2500032533,CDM,637,RC,5434462,NDC,,,,,,outpatient,facility,15,UN,1.92,1.92,0.15,548.68,,1.36,,,percent of total billed charges,,,0.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.92,,,percent of total billed charges,,,1.2,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.35,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.7,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.92,,,fee schedule,,,1.92,,,percent of total billed charges,,,,,,,,,1.92,,,percent of total billed charges,,,1.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.37,,,percent of total billed charges,,,,,,,,,,,,,,,1.04,,,percent of total billed charges,,,1,,,percent of total billed charges,,,1.06,,,percent of total billed charges,,,,,,,,,1.13,,,percent of total billed charges,,,548.68,,,per diem,,,1.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.92,,,percent of total billed charges,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.02,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.3,,,percent of total billed charges,,,1.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.77,,,percent of total billed charges,,,,,,,,,0.71,,,percent of total billed charges,,,0.71,,,percent of total billed charges,,,,,,,,,1.92,,,percent of total billed charges,,,1.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.15,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,1.79,,,percent of total billed charges,,,,,,,,,,,,,,,1.79,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,1.79,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,1.92,,,percent of total billed charges,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.96,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.13,,,percent of total billed charges,,
MULTIVITAMINS LIQ 15 ML UDC,2500032533,CDM,637,RC,5434462,NDC,999,EAPG,,,,outpatient,facility,15,UN,1.92,1.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OMIDRIA 1 -0.3  4 ML  VIAL,2500032538,CDM,636,RC,J1097,HCPCS,6222560004,NDC,,,,inpatient,facility,4,ML,1557.6,1557.6,124.61,1557.6,,,,,,,,,,,,,,1557.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1557.6,,,percent of total billed charges,,,,,,,,,1557.6,,,percent of total billed charges,,,795.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1326.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,934.56,,,percent of total billed charges,,,,,,,,,,,,,,,1557.6,,,percent of total billed charges,,,1323.96,,,percent of total billed charges,,,,,,,,,,,,,,,1557.6,,,percent of total billed charges,,,827.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,623.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1557.6,,,percent of total billed charges,,,,,,,,,,,,,,,124.61,,,percent of total billed charges,,,1557.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1557.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,917.74,,,percent of total billed charges,,
OMIDRIA 1 -0.3  4 ML  VIAL,2500032538,CDM,636,RC,J1097,HCPCS,6222560004,NDC,,,,outpatient,facility,4,ML,1557.6,1557.6,120.36,1557.6,,1104.49,,,percent of total billed charges,,,,,,,,,1557.6,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,1557.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1557.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1557.6,,,fee schedule,,,1557.6,,,percent of total billed charges,,,,,,,,,1557.6,,,percent of total billed charges,,,954.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1109.79,,,percent of total billed charges,,,,,,,,,,,,,,,120.36,,,fee schedule,,,120.36,,,fee schedule,,,120.36,,,fee schedule,,,,,,,,,918.98,,,percent of total billed charges,,,548.68,,,per diem,,,1557.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1557.6,,,percent of total billed charges,,,1323.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,827.24,,,percent of total billed charges,,,1557.6,,,percent of total billed charges,,,1557.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1050.76,,,percent of total billed charges,,,1260.41,,,percent of total billed charges,,,,,,,,,,,,,,,623.04,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1557.6,,,percent of total billed charges,,,,,,,,,,,,,,,124.61,,,percent of total billed charges,,,1557.6,,,percent of total billed charges,,,,,,,,,,,,,,,1557.6,,,percent of total billed charges,,,1557.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,1168.2,,,percent of total billed charges,,,1557.6,,,percent of total billed charges,,,1557.6,,,percent of total billed charges,,,1557.6,,,percent of total billed charges,,,,,,,,,1092.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,778.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,917.74,,,percent of total billed charges,,
OMIDRIA 1 -0.3  4 ML  VIAL,2500032538,CDM,636,RC,J1097,HCPCS,6222560004,NDC,9324,APC,,outpatient,facility,4,ML,1557.6,1557.6,96.84,1557.6,,,,,,,,380.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,570.08,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1557.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1557.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OMIDRIA 1 -0.3  4 ML  VIAL,2500032538,CDM,636,RC,J1097,HCPCS,6222560004,NDC,436,EAPG,,outpatient,facility,4,ML,1557.6,1557.6,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE HCL 2  JELLY 6 ML,2500032540,CDM,637,RC,2502167376,NDC,,,,,,inpatient,facility,6,UN,19.64,19.64,1.57,19.64,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,,,,,,,19.64,,,percent of total billed charges,,,10.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.78,,,percent of total billed charges,,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,16.69,,,percent of total billed charges,,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,10.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,1.57,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.57,,,percent of total billed charges,,
LIDOCAINE HCL 2  JELLY 6 ML,2500032540,CDM,637,RC,2502167376,NDC,,,,,,outpatient,facility,6,UN,19.64,19.64,1.57,548.68,,13.93,,,percent of total billed charges,,,4.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,19.64,,,percent of total billed charges,,,12.31,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,13.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,13.81,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,7.19,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,19.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,19.64,,,fee schedule,,,19.64,,,percent of total billed charges,,,,,,,,,19.64,,,percent of total billed charges,,,12.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.99,,,percent of total billed charges,,,,,,,,,,,,,,,10.61,,,percent of total billed charges,,,10.21,,,percent of total billed charges,,,10.8,,,percent of total billed charges,,,,,,,,,11.59,,,percent of total billed charges,,,548.68,,,per diem,,,19.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,19.64,,,percent of total billed charges,,,16.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.43,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.25,,,percent of total billed charges,,,15.89,,,percent of total billed charges,,,,,,,,,,,,,,,7.86,,,percent of total billed charges,,,,,,,,,7.27,,,percent of total billed charges,,,7.27,,,percent of total billed charges,,,,,,,,,19.64,,,percent of total billed charges,,,19.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,19.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.57,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,,,,,,,19.64,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,18.27,,,percent of total billed charges,,,,,,,,,,,,,,,18.27,,,percent of total billed charges,,,18.27,,,percent of total billed charges,,,18.27,,,percent of total billed charges,,,14.73,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,19.64,,,percent of total billed charges,,,,,,,,,13.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.82,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,11.57,,,percent of total billed charges,,
LIDOCAINE HCL 2  JELLY 6 ML,2500032540,CDM,637,RC,2502167376,NDC,999,EAPG,,,,outpatient,facility,6,UN,19.64,19.64,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INFLUENZA FLUCELVAX Q PF 0.5ML,2500032542,CDM,636,RC,90674,CPT,,,,,,inpatient,facility,1,UN,96.86,96.86,7.75,96.86,,,,,,,,,,,,,,96.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.86,,,percent of total billed charges,,,,,,,,,96.86,,,percent of total billed charges,,,49.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.12,,,percent of total billed charges,,,,,,,,,,,,,,,96.86,,,percent of total billed charges,,,82.33,,,percent of total billed charges,,,,,,,,,,,,,,,96.86,,,percent of total billed charges,,,51.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,96.86,,,percent of total billed charges,,,,,,,,,,,,,,,7.75,,,percent of total billed charges,,,96.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,96.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.07,,,percent of total billed charges,,
INFLUENZA FLUCELVAX Q PF 0.5ML,2500032542,CDM,636,RC,90674,CPT,,,,,,outpatient,facility,1,UN,96.86,96.86,7.75,548.68,,68.68,,,percent of total billed charges,,,18.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,96.86,,,percent of total billed charges,,,44.35,,,fee schedule,,,41.96,,,fee schedule,,,18.03,,,fee schedule,,,41.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,96.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.21,,,fee schedule,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,18.03,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,96.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,96.86,,,fee schedule,,,96.86,,,percent of total billed charges,,,18.03,,,fee schedule,,,96.86,,,percent of total billed charges,,,59.37,,,percent of total billed charges,,,18.93,,,fee schedule,,,18.93,,,fee schedule,,,,,,,,,18.4,,,fee schedule,,,18.03,,,fee schedule,,,18.93,,,fee schedule,,,69.01,,,percent of total billed charges,,,,,,,,,27.04,,,fee schedule,,,34.17,,,fee schedule,,,34.17,,,fee schedule,,,34.17,,,fee schedule,,,18.57,,,fee schedule,,,57.15,,,percent of total billed charges,,,548.68,,,per diem,,,96.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,96.86,,,percent of total billed charges,,,82.33,,,percent of total billed charges,,,17.4,,,fee schedule,,,19.29,,,fee schedule,,,19.32,,,fee schedule,,,51.44,,,percent of total billed charges,,,96.86,,,percent of total billed charges,,,96.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.03,,,fee schedule,,,18.03,,,fee schedule,,,65.34,,,percent of total billed charges,,,78.38,,,percent of total billed charges,,,,,,,,,19.14,,,fee schedule,,,38.74,,,percent of total billed charges,,,,,,,,,79.31,,,fee schedule,,,57.07,,,fee schedule,,,18.03,,,fee schedule,,,96.86,,,percent of total billed charges,,,22.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,22.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,7.75,,,percent of total billed charges,,,96.86,,,percent of total billed charges,,,18.03,,,fee schedule,,,27.05,,,fee schedule,,,96.86,,,percent of total billed charges,,,96.86,,,percent of total billed charges,,,18.03,,,fee schedule,,,33.89,,,fee schedule,,,18.03,,,fee schedule,,,18.57,,,fee schedule,,,29.38,,,fee schedule,,,39.17,,,fee schedule,,,22.03,,,fee schedule,,,35.46,,,fee schedule,,,96.86,,,percent of total billed charges,,,96.86,,,percent of total billed charges,,,96.86,,,percent of total billed charges,,,30.58,,,fee schedule,,,67.91,,,percent of total billed charges,,,18.03,,,fee schedule,,,19.23,,,fee schedule,,,18.03,,,fee schedule,,,18.03,,,fee schedule,,,18.4,,,fee schedule,,,48.43,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,18.4,,,fee schedule,,,18.93,,,fee schedule,,,57.07,,,percent of total billed charges,,
INFLUENZA FLUCELVAX Q PF 0.5ML,2500032542,CDM,636,RC,90674,CPT,414,EAPG,,,,outpatient,facility,1,UN,96.86,96.86,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SOD HYALURONATE IA INJ 25 MG,2500032544,CDM,636,RC,J7321,HCPCS,8913044441,NDC,,,,inpatient,facility,2.5,UN,782.79,782.79,62.62,782.79,,,,,,,,,,,,,,782.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,782.79,,,percent of total billed charges,,,,,,,,,782.79,,,percent of total billed charges,,,399.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,666.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,469.67,,,percent of total billed charges,,,,,,,,,,,,,,,782.79,,,percent of total billed charges,,,665.37,,,percent of total billed charges,,,,,,,,,,,,,,,782.79,,,percent of total billed charges,,,415.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,782.79,,,percent of total billed charges,,,,,,,,,,,,,,,62.62,,,percent of total billed charges,,,782.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,782.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,461.22,,,percent of total billed charges,,
SOD HYALURONATE IA INJ 25 MG,2500032544,CDM,636,RC,J7321,HCPCS,8913044441,NDC,,,,outpatient,facility,2.5,UN,782.79,782.79,62.62,782.79,,555.08,,,percent of total billed charges,,,191,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,782.79,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,782.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,286.5,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,101.84,,,fee schedule,,,782.79,,,fee schedule,,,782.79,,,percent of total billed charges,,,,,,,,,782.79,,,percent of total billed charges,,,479.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.74,,,percent of total billed charges,,,,,,,,,,,,,,,73.1,,,fee schedule,,,73.1,,,fee schedule,,,73.1,,,fee schedule,,,,,,,,,461.85,,,percent of total billed charges,,,548.68,,,per diem,,,782.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,782.79,,,percent of total billed charges,,,665.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,415.74,,,percent of total billed charges,,,782.79,,,percent of total billed charges,,,782.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,528.07,,,percent of total billed charges,,,633.43,,,percent of total billed charges,,,,,,,,,,,,,,,313.12,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,782.79,,,percent of total billed charges,,,782.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,782.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,62.62,,,percent of total billed charges,,,782.79,,,percent of total billed charges,,,,,,,,,,,,,,,782.79,,,percent of total billed charges,,,782.79,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,78.33,,,fee schedule,,,782.79,,,percent of total billed charges,,,782.79,,,percent of total billed charges,,,782.79,,,percent of total billed charges,,,,,,,,,548.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.39,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,461.22,,,percent of total billed charges,,
SOD HYALURONATE IA INJ 25 MG,2500032544,CDM,636,RC,J7321,HCPCS,8913044441,NDC,436,EAPG,,outpatient,facility,2.5,UN,782.79,782.79,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
UMECLIDINIUM/VILANTEROL 7 PUFF,2500032556,CDM,637,RC,173086906,NDC,,,,,,inpatient,facility,7,UN,26.9,26.9,2.15,26.9,,,,,,,,,,,,,,26.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.9,,,percent of total billed charges,,,,,,,,,26.9,,,percent of total billed charges,,,13.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.14,,,percent of total billed charges,,,,,,,,,,,,,,,26.9,,,percent of total billed charges,,,22.86,,,percent of total billed charges,,,,,,,,,,,,,,,26.9,,,percent of total billed charges,,,14.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,26.9,,,percent of total billed charges,,,,,,,,,,,,,,,2.15,,,percent of total billed charges,,,26.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.85,,,percent of total billed charges,,
UMECLIDINIUM/VILANTEROL 7 PUFF,2500032556,CDM,637,RC,173086906,NDC,,,,,,outpatient,facility,7,UN,26.9,26.9,2.15,548.68,,19.07,,,percent of total billed charges,,,6.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,26.9,,,percent of total billed charges,,,16.86,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,18.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,18.91,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,26.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.85,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,26.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,26.9,,,fee schedule,,,26.9,,,percent of total billed charges,,,,,,,,,26.9,,,percent of total billed charges,,,16.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.17,,,percent of total billed charges,,,,,,,,,,,,,,,14.53,,,percent of total billed charges,,,13.99,,,percent of total billed charges,,,14.79,,,percent of total billed charges,,,,,,,,,15.87,,,percent of total billed charges,,,548.68,,,per diem,,,26.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,26.9,,,percent of total billed charges,,,22.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.29,,,percent of total billed charges,,,26.9,,,percent of total billed charges,,,26.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.15,,,percent of total billed charges,,,21.77,,,percent of total billed charges,,,,,,,,,,,,,,,10.76,,,percent of total billed charges,,,,,,,,,9.95,,,percent of total billed charges,,,9.95,,,percent of total billed charges,,,,,,,,,26.9,,,percent of total billed charges,,,26.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.15,,,percent of total billed charges,,,26.9,,,percent of total billed charges,,,,,,,,,,,,,,,26.9,,,percent of total billed charges,,,26.9,,,percent of total billed charges,,,,,,,,,25.02,,,percent of total billed charges,,,,,,,,,,,,,,,25.02,,,percent of total billed charges,,,25.02,,,percent of total billed charges,,,25.02,,,percent of total billed charges,,,20.17,,,percent of total billed charges,,,26.9,,,percent of total billed charges,,,26.9,,,percent of total billed charges,,,26.9,,,percent of total billed charges,,,,,,,,,18.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.45,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15.85,,,percent of total billed charges,,
UMECLIDINIUM/VILANTEROL 7 PUFF,2500032556,CDM,637,RC,173086906,NDC,999,EAPG,,,,outpatient,facility,7,UN,26.9,26.9,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PROPOFOL IV 10 MG/ML 10 ML AMP,2500032558,CDM,636,RC,J2704,HCPCS,6332326910,NDC,,,,inpatient,facility,10,ML,9.9,9.9,0.79,9.9,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,5.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.94,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,5.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,0.79,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.83,,,percent of total billed charges,,
PROPOFOL IV 10 MG/ML 10 ML AMP,2500032558,CDM,636,RC,J2704,HCPCS,6332326910,NDC,,,,outpatient,facility,10,ML,9.9,9.9,0.09,548.68,,7.02,,,percent of total billed charges,,,2.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,9.9,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,3.62,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9.9,,,fee schedule,,,9.9,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,6.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,5.84,,,percent of total billed charges,,,548.68,,,per diem,,,9.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9.9,,,percent of total billed charges,,,8.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5.26,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.68,,,percent of total billed charges,,,8.01,,,percent of total billed charges,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,9.9,,,percent of total billed charges,,,9.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.79,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.09,,,fee schedule,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,9.9,,,percent of total billed charges,,,,,,,,,6.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5.83,,,percent of total billed charges,,
PROPOFOL IV 10 MG/ML 10 ML AMP,2500032558,CDM,636,RC,J2704,HCPCS,6332326910,NDC,496,EAPG,,outpatient,facility,10,ML,9.9,9.9,145.31,219.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.42,,,fee schedule,,,145.31,,,fee schedule,,,195.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,145.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MOMETASONE 200MCG 13GM INH,2500032584,CDM,637,RC,7820611301,NDC,,,,,,inpatient,facility,13,UN,502.39,502.39,40.19,502.39,,,,,,,,,,,,,,502.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,502.39,,,percent of total billed charges,,,,,,,,,502.39,,,percent of total billed charges,,,256.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,427.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.43,,,percent of total billed charges,,,,,,,,,,,,,,,502.39,,,percent of total billed charges,,,427.03,,,percent of total billed charges,,,,,,,,,,,,,,,502.39,,,percent of total billed charges,,,266.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,502.39,,,percent of total billed charges,,,,,,,,,,,,,,,40.19,,,percent of total billed charges,,,502.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,502.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.01,,,percent of total billed charges,,
MOMETASONE 200MCG 13GM INH,2500032584,CDM,637,RC,7820611301,NDC,,,,,,outpatient,facility,13,UN,502.39,502.39,40.19,548.68,,356.24,,,percent of total billed charges,,,122.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,502.39,,,percent of total billed charges,,,314.85,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,353.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,353.18,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,502.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,183.87,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,502.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,502.39,,,fee schedule,,,502.39,,,percent of total billed charges,,,,,,,,,502.39,,,percent of total billed charges,,,307.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.95,,,percent of total billed charges,,,,,,,,,,,,,,,271.29,,,percent of total billed charges,,,261.24,,,percent of total billed charges,,,276.31,,,percent of total billed charges,,,,,,,,,296.41,,,percent of total billed charges,,,548.68,,,per diem,,,502.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,502.39,,,percent of total billed charges,,,427.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.82,,,percent of total billed charges,,,502.39,,,percent of total billed charges,,,502.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,338.91,,,percent of total billed charges,,,406.53,,,percent of total billed charges,,,,,,,,,,,,,,,200.96,,,percent of total billed charges,,,,,,,,,185.88,,,percent of total billed charges,,,185.88,,,percent of total billed charges,,,,,,,,,502.39,,,percent of total billed charges,,,502.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,502.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.19,,,percent of total billed charges,,,502.39,,,percent of total billed charges,,,,,,,,,,,,,,,502.39,,,percent of total billed charges,,,502.39,,,percent of total billed charges,,,,,,,,,467.32,,,percent of total billed charges,,,,,,,,,,,,,,,467.32,,,percent of total billed charges,,,467.32,,,percent of total billed charges,,,467.32,,,percent of total billed charges,,,376.79,,,percent of total billed charges,,,502.39,,,percent of total billed charges,,,502.39,,,percent of total billed charges,,,502.39,,,percent of total billed charges,,,,,,,,,352.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,251.19,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,296.01,,,percent of total billed charges,,
MOMETASONE 200MCG 13GM INH,2500032584,CDM,637,RC,7820611301,NDC,999,EAPG,,,,outpatient,facility,13,UN,502.39,502.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NALTREX MICROSPHR 380 MG INJ,2500032587,CDM,636,RC,J2315,HCPCS,6575730001,NDC,,,,inpatient,facility,380,UN,4950.69,4950.69,396.06,4950.69,,,,,,,,,,,,,,4950.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4950.69,,,percent of total billed charges,,,,,,,,,4950.69,,,percent of total billed charges,,,2527.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4216.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2970.41,,,percent of total billed charges,,,,,,,,,,,,,,,4950.69,,,percent of total billed charges,,,4208.09,,,percent of total billed charges,,,,,,,,,,,,,,,4950.69,,,percent of total billed charges,,,2629.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1980.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,4950.69,,,percent of total billed charges,,,,,,,,,,,,,,,396.06,,,percent of total billed charges,,,4950.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4950.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2916.95,,,percent of total billed charges,,
NALTREX MICROSPHR 380 MG INJ,2500032587,CDM,636,RC,J2315,HCPCS,6575730001,NDC,,,,outpatient,facility,380,UN,4950.69,4950.69,2.55,4950.69,,3510.53,,,percent of total billed charges,,,,,,,,,4950.69,,,percent of total billed charges,,,5.32,,,fee schedule,,,5.03,,,fee schedule,,,,,,,,,5.03,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4950.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.23,,,fee schedule,,,4950.69,,,fee schedule,,,4950.69,,,percent of total billed charges,,,,,,,,,4950.69,,,percent of total billed charges,,,3034.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3527.37,,,percent of total billed charges,,,,,,,,,,,,,,,3.96,,,fee schedule,,,3.96,,,fee schedule,,,3.96,,,fee schedule,,,,,,,,,2920.91,,,percent of total billed charges,,,548.68,,,per diem,,,4950.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,4950.69,,,percent of total billed charges,,,4208.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2629.31,,,percent of total billed charges,,,2.83,,,fee schedule,,,2.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3339.74,,,percent of total billed charges,,,4006.1,,,percent of total billed charges,,,,,,,,,,,,,,,1980.28,,,percent of total billed charges,,,,,,,,,9.19,,,fee schedule,,,6.61,,,fee schedule,,,,,,,,,4950.69,,,percent of total billed charges,,,,,,,,,,,,,,,396.06,,,percent of total billed charges,,,4950.69,,,percent of total billed charges,,,,,,,,,,,,,,,4950.69,,,percent of total billed charges,,,4950.69,,,percent of total billed charges,,,,,,,,,3.93,,,fee schedule,,,,,,,,,,,,,,,3.41,,,fee schedule,,,4.54,,,fee schedule,,,2.55,,,fee schedule,,,4.25,,,fee schedule,,,4950.69,,,percent of total billed charges,,,4950.69,,,percent of total billed charges,,,4950.69,,,percent of total billed charges,,,,,,,,,3470.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2475.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2916.95,,,percent of total billed charges,,
NALTREX MICROSPHR 380 MG INJ,2500032587,CDM,636,RC,J2315,HCPCS,6575730001,NDC,759,APC,,outpatient,facility,380,UN,4950.69,4950.69,3.96,1811.95,,,,,,,,4.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,4.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.16,,,fee schedule,,,,,,,,,1811.95,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,fee schedule,,,,,,,,,,,,,,,4.33,,,fee schedule,,,4.33,,,fee schedule,,,,,,,,,4.12,,,fee schedule,,,4.12,,,fee schedule,,,4.33,,,fee schedule,,,,,,,,,,,,,,,6.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,4.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.96,,,fee schedule,,,4.41,,,fee schedule,,,4.33,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,fee schedule,,,4.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,4.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,fee schedule,,,,,,,,,5.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,4.12,,,fee schedule,,,4.12,,,fee schedule,,,,,,,,,,,,,,,4.12,,,fee schedule,,,,,,,,,4.12,,,fee schedule,,,4.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,fee schedule,,,,,,,,,,,,,,,4.28,,,fee schedule,,,4.12,,,fee schedule,,,,,,,,,4.12,,,fee schedule,,,,,,,,,4.12,,,fee schedule,,,4.33,,,fee schedule,,,,,,,,
NALTREX MICROSPHR 380 MG INJ,2500032587,CDM,636,RC,J2315,HCPCS,6575730001,NDC,444,EAPG,,outpatient,facility,380,UN,4950.69,4950.69,1304.36,1969.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1969.58,,,fee schedule,,,1304.36,,,fee schedule,,,1750.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SP-INFLIXIMAB-DYYB 100 MG INJ,2500032591,CDM,636,RC,Q5103,HCPCS,69080901,NDC,,,,inpatient,facility,100,UN,0.03,0.03,0.01,0.03,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,0.03,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,
SP-INFLIXIMAB-DYYB 100 MG INJ,2500032591,CDM,636,RC,Q5103,HCPCS,69080901,NDC,,,,outpatient,facility,100,UN,0.03,0.03,0.01,548.68,,0.02,,,percent of total billed charges,,,,,,,,,0.03,,,percent of total billed charges,,,13.84,,,fee schedule,,,13.09,,,fee schedule,,,,,,,,,13.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.03,,,fee schedule,,,0.03,,,percent of total billed charges,,,,,,,,,0.03,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,fee schedule,,,0.03,,,fee schedule,,,0.03,,,fee schedule,,,,,,,,,0.02,,,percent of total billed charges,,,548.68,,,per diem,,,0.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.02,,,percent of total billed charges,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.03,,,fee schedule,,,0.03,,,fee schedule,,,,,,,,,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.03,,,percent of total billed charges,,,,,,,,,,,,,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,0.03,,,fee schedule,,,,,,,,,,,,,,,0.03,,,fee schedule,,,0.03,,,fee schedule,,,0.03,,,fee schedule,,,0.03,,,fee schedule,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,0.03,,,percent of total billed charges,,,,,,,,,0.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.02,,,percent of total billed charges,,
SP-INFLIXIMAB-DYYB 100 MG INJ,2500032591,CDM,636,RC,Q5103,HCPCS,69080901,NDC,1847,APC,,outpatient,facility,100,UN,0.03,0.03,0.01,17.32,,,,,,,,11.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,11.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.67,,,fee schedule,,,,,,,,,0.01,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,fee schedule,,,,,,,,,,,,,,,12.13,,,fee schedule,,,12.13,,,fee schedule,,,,,,,,,11.55,,,fee schedule,,,11.55,,,fee schedule,,,12.13,,,fee schedule,,,,,,,,,,,,,,,17.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.09,,,fee schedule,,,12.36,,,fee schedule,,,12.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,fee schedule,,,11.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,12.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,fee schedule,,,,,,,,,14.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,14.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,11.55,,,fee schedule,,,11.55,,,fee schedule,,,,,,,,,,,,,,,11.55,,,fee schedule,,,,,,,,,11.55,,,fee schedule,,,11.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.55,,,fee schedule,,,,,,,,,,,,,,,12.01,,,fee schedule,,,11.55,,,fee schedule,,,,,,,,,11.55,,,fee schedule,,,,,,,,,11.55,,,fee schedule,,,12.13,,,fee schedule,,,,,,,,
SP-INFLIXIMAB-DYYB 100 MG INJ,2500032591,CDM,636,RC,Q5103,HCPCS,69080901,NDC,444,EAPG,,outpatient,facility,100,UN,0.03,0.03,1304.36,1969.58,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1969.58,,,fee schedule,,,1304.36,,,fee schedule,,,1750.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,1304.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AVELUMAB 200 MG/10 ML VIAL,2500032595,CDM,636,RC,J9023,HCPCS,4408735351,NDC,,,,inpatient,facility,10,ML,6202.84,6202.84,496.23,6202.84,,,,,,,,,,,,,,6202.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6202.84,,,percent of total billed charges,,,,,,,,,6202.84,,,percent of total billed charges,,,3167.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5282.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3721.7,,,percent of total billed charges,,,,,,,,,,,,,,,6202.84,,,percent of total billed charges,,,5272.41,,,percent of total billed charges,,,,,,,,,,,,,,,6202.84,,,percent of total billed charges,,,3294.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2481.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6202.84,,,percent of total billed charges,,,,,,,,,,,,,,,496.23,,,percent of total billed charges,,,6202.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6202.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3654.71,,,percent of total billed charges,,
AVELUMAB 200 MG/10 ML VIAL,2500032595,CDM,636,RC,J9023,HCPCS,4408735351,NDC,,,,outpatient,facility,10,ML,6202.84,6202.84,60.18,6202.84,,92.53,,,fee schedule,,,,,,,,,6202.84,,,percent of total billed charges,,,122.96,,,fee schedule,,,116.33,,,fee schedule,,,,,,,,,116.33,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,6202.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6202.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6202.84,,,fee schedule,,,6202.84,,,percent of total billed charges,,,,,,,,,6202.84,,,percent of total billed charges,,,3801.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4419.52,,,percent of total billed charges,,,,,,,,,,,,,,,92.37,,,fee schedule,,,92.37,,,fee schedule,,,92.37,,,fee schedule,,,,,,,,,3659.68,,,percent of total billed charges,,,548.68,,,per diem,,,6202.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6202.84,,,percent of total billed charges,,,5272.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3294.33,,,percent of total billed charges,,,6202.84,,,percent of total billed charges,,,6202.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4184.44,,,percent of total billed charges,,,5019.34,,,percent of total billed charges,,,,,,,,,,,,,,,2481.14,,,percent of total billed charges,,,,,,,,,216.66,,,fee schedule,,,155.9,,,fee schedule,,,,,,,,,6202.84,,,percent of total billed charges,,,,,,,,,,,,,,,496.23,,,percent of total billed charges,,,6202.84,,,percent of total billed charges,,,,,,,,,,,,,,,6202.84,,,percent of total billed charges,,,6202.84,,,percent of total billed charges,,,,,,,,,92.59,,,fee schedule,,,,,,,,,,,,,,,80.25,,,fee schedule,,,107,,,fee schedule,,,60.18,,,fee schedule,,,98.31,,,fee schedule,,,6202.84,,,percent of total billed charges,,,6202.84,,,percent of total billed charges,,,6202.84,,,percent of total billed charges,,,,,,,,,4348.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3101.42,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,3654.71,,,percent of total billed charges,,
AVELUMAB 200 MG/10 ML VIAL,2500032595,CDM,636,RC,J9023,HCPCS,4408735351,NDC,9491,APC,,outpatient,facility,10,ML,6202.84,6202.84,93.07,2270.24,,,,,,,,99.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,96.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.92,,,fee schedule,,,,,,,,,2270.24,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,96.95,,,fee schedule,,,,,,,,,,,,,,,101.8,,,fee schedule,,,101.8,,,fee schedule,,,,,,,,,96.95,,,fee schedule,,,96.95,,,fee schedule,,,101.8,,,fee schedule,,,,,,,,,,,,,,,145.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,96.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.07,,,fee schedule,,,103.74,,,fee schedule,,,101.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.95,,,fee schedule,,,96.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,100.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,96.95,,,fee schedule,,,,,,,,,121.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,121.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,96.95,,,fee schedule,,,96.95,,,fee schedule,,,,,,,,,,,,,,,96.95,,,fee schedule,,,,,,,,,96.95,,,fee schedule,,,99.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.95,,,fee schedule,,,,,,,,,,,,,,,100.83,,,fee schedule,,,96.95,,,fee schedule,,,,,,,,,96.95,,,fee schedule,,,,,,,,,96.95,,,fee schedule,,,101.8,,,fee schedule,,,,,,,,
AVELUMAB 200 MG/10 ML VIAL,2500032595,CDM,636,RC,J9023,HCPCS,4408735351,NDC,463,EAPG,,outpatient,facility,10,ML,6202.84,6202.84,7053.67,10651.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10651.04,,,fee schedule,,,7053.67,,,fee schedule,,,9468.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DURVALUMAB 120 MG/2.4 ML VIAL,2500032597,CDM,636,RC,J9173,HCPCS,310450012,NDC,,,,inpatient,facility,2.4,UN,3189.54,3189.54,255.16,3189.54,,,,,,,,,,,,,,3189.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3189.54,,,percent of total billed charges,,,,,,,,,3189.54,,,percent of total billed charges,,,1628.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2716.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1913.72,,,percent of total billed charges,,,,,,,,,,,,,,,3189.54,,,percent of total billed charges,,,2711.11,,,percent of total billed charges,,,,,,,,,,,,,,,3189.54,,,percent of total billed charges,,,1693.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1275.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3189.54,,,percent of total billed charges,,,,,,,,,,,,,,,255.16,,,percent of total billed charges,,,3189.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3189.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1879.28,,,percent of total billed charges,,
DURVALUMAB 120 MG/2.4 ML VIAL,2500032597,CDM,636,RC,J9173,HCPCS,310450012,NDC,,,,outpatient,facility,2.4,UN,3189.54,3189.54,53.21,3189.54,,80.52,,,fee schedule,,,,,,,,,3189.54,,,percent of total billed charges,,,106.27,,,fee schedule,,,100.54,,,fee schedule,,,,,,,,,100.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3189.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3189.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3189.54,,,fee schedule,,,3189.54,,,percent of total billed charges,,,,,,,,,3189.54,,,percent of total billed charges,,,1954.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2272.55,,,percent of total billed charges,,,,,,,,,,,,,,,80.71,,,fee schedule,,,80.71,,,fee schedule,,,80.71,,,fee schedule,,,,,,,,,1881.83,,,percent of total billed charges,,,548.68,,,per diem,,,3189.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3189.54,,,percent of total billed charges,,,2711.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1693.96,,,percent of total billed charges,,,3189.54,,,percent of total billed charges,,,3189.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2151.66,,,percent of total billed charges,,,2580.98,,,percent of total billed charges,,,,,,,,,,,,,,,1275.82,,,percent of total billed charges,,,,,,,,,191.55,,,fee schedule,,,137.83,,,fee schedule,,,,,,,,,3189.54,,,percent of total billed charges,,,,,,,,,,,,,,,255.16,,,percent of total billed charges,,,3189.54,,,percent of total billed charges,,,,,,,,,,,,,,,3189.54,,,percent of total billed charges,,,3189.54,,,percent of total billed charges,,,,,,,,,81.86,,,fee schedule,,,,,,,,,,,,,,,70.95,,,fee schedule,,,94.6,,,fee schedule,,,53.21,,,fee schedule,,,84.96,,,fee schedule,,,3189.54,,,percent of total billed charges,,,3189.54,,,percent of total billed charges,,,3189.54,,,percent of total billed charges,,,,,,,,,2236.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1594.77,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1879.28,,,percent of total billed charges,,
DURVALUMAB 120 MG/2.4 ML VIAL,2500032597,CDM,636,RC,J9173,HCPCS,310450012,NDC,9492,APC,,outpatient,facility,2.4,UN,3189.54,3189.54,80.52,1167.37,,,,,,,,86.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.72,,,fee schedule,,,,,,,,,1167.37,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,,,,,,,88.07,,,fee schedule,,,88.07,,,fee schedule,,,,,,,,,83.88,,,fee schedule,,,83.88,,,fee schedule,,,88.07,,,fee schedule,,,,,,,,,,,,,,,125.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.52,,,fee schedule,,,89.75,,,fee schedule,,,88.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,83.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,87.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,104.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,104.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,83.88,,,fee schedule,,,83.88,,,fee schedule,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,83.88,,,fee schedule,,,86.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,,,,,,,87.24,,,fee schedule,,,83.88,,,fee schedule,,,,,,,,,83.88,,,fee schedule,,,,,,,,,83.88,,,fee schedule,,,88.07,,,fee schedule,,,,,,,,
DURVALUMAB 120 MG/2.4 ML VIAL,2500032597,CDM,636,RC,J9173,HCPCS,310450012,NDC,461,EAPG,,outpatient,facility,2.4,UN,3189.54,3189.54,83.88,126.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.66,,,fee schedule,,,83.88,,,fee schedule,,,112.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,83.88,,,fee schedule,,,83.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DURVALUMAB 500 MG/10 ML VIAL,2500032598,CDM,636,RC,J9173,HCPCS,310461150,NDC,,,,inpatient,facility,10,ML,13622.07,13622.07,1089.77,13622.07,,,,,,,,,,,,,,13622.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13622.07,,,percent of total billed charges,,,,,,,,,13622.07,,,percent of total billed charges,,,6955.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11601.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8173.24,,,percent of total billed charges,,,,,,,,,,,,,,,13622.07,,,percent of total billed charges,,,11578.76,,,percent of total billed charges,,,,,,,,,,,,,,,13622.07,,,percent of total billed charges,,,7234.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5448.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,13622.07,,,percent of total billed charges,,,,,,,,,,,,,,,1089.77,,,percent of total billed charges,,,13622.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13622.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8026.12,,,percent of total billed charges,,
DURVALUMAB 500 MG/10 ML VIAL,2500032598,CDM,636,RC,J9173,HCPCS,310461150,NDC,,,,outpatient,facility,10,ML,13622.07,13622.07,53.21,13622.07,,80.52,,,fee schedule,,,,,,,,,13622.07,,,percent of total billed charges,,,106.27,,,fee schedule,,,100.54,,,fee schedule,,,,,,,,,100.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,13622.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,13622.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,13622.07,,,fee schedule,,,13622.07,,,percent of total billed charges,,,,,,,,,13622.07,,,percent of total billed charges,,,8348.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9705.72,,,percent of total billed charges,,,,,,,,,,,,,,,80.71,,,fee schedule,,,80.71,,,fee schedule,,,80.71,,,fee schedule,,,,,,,,,8037.02,,,percent of total billed charges,,,548.68,,,per diem,,,13622.07,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,13622.07,,,percent of total billed charges,,,11578.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7234.68,,,percent of total billed charges,,,13622.07,,,percent of total billed charges,,,13622.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9189.45,,,percent of total billed charges,,,11022.98,,,percent of total billed charges,,,,,,,,,,,,,,,5448.83,,,percent of total billed charges,,,,,,,,,191.55,,,fee schedule,,,137.83,,,fee schedule,,,,,,,,,13622.07,,,percent of total billed charges,,,,,,,,,,,,,,,1089.77,,,percent of total billed charges,,,13622.07,,,percent of total billed charges,,,,,,,,,,,,,,,13622.07,,,percent of total billed charges,,,13622.07,,,percent of total billed charges,,,,,,,,,81.86,,,fee schedule,,,,,,,,,,,,,,,70.95,,,fee schedule,,,94.6,,,fee schedule,,,53.21,,,fee schedule,,,84.96,,,fee schedule,,,13622.07,,,percent of total billed charges,,,13622.07,,,percent of total billed charges,,,13622.07,,,percent of total billed charges,,,,,,,,,9550.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6811.03,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,8026.12,,,percent of total billed charges,,
DURVALUMAB 500 MG/10 ML VIAL,2500032598,CDM,636,RC,J9173,HCPCS,310461150,NDC,9492,APC,,outpatient,facility,10,ML,13622.07,13622.07,80.52,4985.68,,,,,,,,86.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.72,,,fee schedule,,,,,,,,,4985.68,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,,,,,,,88.07,,,fee schedule,,,88.07,,,fee schedule,,,,,,,,,83.88,,,fee schedule,,,83.88,,,fee schedule,,,88.07,,,fee schedule,,,,,,,,,,,,,,,125.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.52,,,fee schedule,,,89.75,,,fee schedule,,,88.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,83.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,87.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,104.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,104.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,83.88,,,fee schedule,,,83.88,,,fee schedule,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,83.88,,,fee schedule,,,86.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,,,,,,,87.24,,,fee schedule,,,83.88,,,fee schedule,,,,,,,,,83.88,,,fee schedule,,,,,,,,,83.88,,,fee schedule,,,88.07,,,fee schedule,,,,,,,,
DURVALUMAB 500 MG/10 ML VIAL,2500032598,CDM,636,RC,J9173,HCPCS,310461150,NDC,461,EAPG,,outpatient,facility,10,ML,13622.07,13622.07,83.88,126.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.66,,,fee schedule,,,83.88,,,fee schedule,,,112.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,83.88,,,fee schedule,,,83.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,,,,,,,83.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PREDNSLNE 1  OPTH SUSP 1ML BTL,2500032603,CDM,637,RC,6131463705,NDC,,,,,,inpatient,facility,1,UN,36.5,36.5,2.92,36.5,,,,,,,,,,,,,,36.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.5,,,percent of total billed charges,,,,,,,,,36.5,,,percent of total billed charges,,,18.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.9,,,percent of total billed charges,,,,,,,,,,,,,,,36.5,,,percent of total billed charges,,,31.02,,,percent of total billed charges,,,,,,,,,,,,,,,36.5,,,percent of total billed charges,,,19.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,36.5,,,percent of total billed charges,,,,,,,,,,,,,,,2.92,,,percent of total billed charges,,,36.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.51,,,percent of total billed charges,,
PREDNSLNE 1  OPTH SUSP 1ML BTL,2500032603,CDM,637,RC,6131463705,NDC,,,,,,outpatient,facility,1,UN,36.5,36.5,2.92,548.68,,25.88,,,percent of total billed charges,,,8.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,36.5,,,percent of total billed charges,,,22.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,25.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,25.66,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,36.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,13.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,36.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,36.5,,,fee schedule,,,36.5,,,percent of total billed charges,,,,,,,,,36.5,,,percent of total billed charges,,,22.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.01,,,percent of total billed charges,,,,,,,,,,,,,,,19.71,,,percent of total billed charges,,,18.98,,,percent of total billed charges,,,20.08,,,percent of total billed charges,,,,,,,,,21.54,,,percent of total billed charges,,,548.68,,,per diem,,,36.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,36.5,,,percent of total billed charges,,,31.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.39,,,percent of total billed charges,,,36.5,,,percent of total billed charges,,,36.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.62,,,percent of total billed charges,,,29.54,,,percent of total billed charges,,,,,,,,,,,,,,,14.6,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,13.5,,,percent of total billed charges,,,,,,,,,36.5,,,percent of total billed charges,,,36.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,36.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.92,,,percent of total billed charges,,,36.5,,,percent of total billed charges,,,,,,,,,,,,,,,36.5,,,percent of total billed charges,,,36.5,,,percent of total billed charges,,,,,,,,,33.95,,,percent of total billed charges,,,,,,,,,,,,,,,33.95,,,percent of total billed charges,,,33.95,,,percent of total billed charges,,,33.95,,,percent of total billed charges,,,27.38,,,percent of total billed charges,,,36.5,,,percent of total billed charges,,,36.5,,,percent of total billed charges,,,36.5,,,percent of total billed charges,,,,,,,,,25.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.25,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,21.51,,,percent of total billed charges,,
PREDNSLNE 1  OPTH SUSP 1ML BTL,2500032603,CDM,637,RC,6131463705,NDC,999,EAPG,,,,outpatient,facility,1,UN,36.5,36.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUSPIRONE 15 MG TAB,2500032607,CDM,637,RC,904689961,NDC,,,,,,inpatient,facility,15,UN,1.78,1.78,0.14,1.78,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,1.78,,,percent of total billed charges,,,0.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.07,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,0.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,0.14,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.05,,,percent of total billed charges,,
BUSPIRONE 15 MG TAB,2500032607,CDM,637,RC,904689961,NDC,,,,,,outpatient,facility,15,UN,1.78,1.78,0.14,548.68,,1.26,,,percent of total billed charges,,,0.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1.78,,,percent of total billed charges,,,1.12,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,1.25,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1.78,,,fee schedule,,,1.78,,,percent of total billed charges,,,,,,,,,1.78,,,percent of total billed charges,,,1.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.27,,,percent of total billed charges,,,,,,,,,,,,,,,0.96,,,percent of total billed charges,,,0.93,,,percent of total billed charges,,,0.98,,,percent of total billed charges,,,,,,,,,1.05,,,percent of total billed charges,,,548.68,,,per diem,,,1.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1.78,,,percent of total billed charges,,,1.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.95,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.2,,,percent of total billed charges,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,1.78,,,percent of total billed charges,,,1.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.14,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,1.66,,,percent of total billed charges,,,,,,,,,,,,,,,1.66,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,1.66,,,percent of total billed charges,,,1.33,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,1.78,,,percent of total billed charges,,,,,,,,,1.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.89,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1.05,,,percent of total billed charges,,
BUSPIRONE 15 MG TAB,2500032607,CDM,637,RC,904689961,NDC,999,EAPG,,,,outpatient,facility,15,UN,1.78,1.78,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NIVOLUMAB 240MG/24ML VIAL,2500032637,CDM,636,RC,J9299,HCPCS,3373413,NDC,,,,inpatient,facility,24,ML,25194.31,25194.31,2015.54,25194.31,,,,,,,,,,,,,,25194.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25194.31,,,percent of total billed charges,,,,,,,,,25194.31,,,percent of total billed charges,,,12864.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21457.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15116.59,,,percent of total billed charges,,,,,,,,,,,,,,,25194.31,,,percent of total billed charges,,,21415.16,,,percent of total billed charges,,,,,,,,,,,,,,,25194.31,,,percent of total billed charges,,,13380.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10077.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,25194.31,,,percent of total billed charges,,,,,,,,,,,,,,,2015.54,,,percent of total billed charges,,,25194.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25194.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14844.49,,,percent of total billed charges,,
NIVOLUMAB 240MG/24ML VIAL,2500032637,CDM,636,RC,J9299,HCPCS,3373413,NDC,,,,outpatient,facility,24,ML,25194.31,25194.31,20.17,25194.31,,31.09,,,fee schedule,,,,,,,,,25194.31,,,percent of total billed charges,,,41.02,,,fee schedule,,,38.8,,,fee schedule,,,,,,,,,38.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,25194.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,25194.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,25194.31,,,fee schedule,,,25194.31,,,percent of total billed charges,,,,,,,,,25194.31,,,percent of total billed charges,,,15441.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17950.95,,,percent of total billed charges,,,,,,,,,,,,,,,31.09,,,fee schedule,,,31.09,,,fee schedule,,,31.09,,,fee schedule,,,,,,,,,14864.64,,,percent of total billed charges,,,548.68,,,per diem,,,25194.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,25194.31,,,percent of total billed charges,,,21415.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13380.7,,,percent of total billed charges,,,25194.31,,,percent of total billed charges,,,25194.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16996.08,,,percent of total billed charges,,,20387.24,,,percent of total billed charges,,,,,,,,,,,,,,,10077.72,,,percent of total billed charges,,,,,,,,,72.6,,,fee schedule,,,52.24,,,fee schedule,,,,,,,,,25194.31,,,percent of total billed charges,,,,,,,,,,,,,,,2015.54,,,percent of total billed charges,,,25194.31,,,percent of total billed charges,,,,,,,,,,,,,,,25194.31,,,percent of total billed charges,,,25194.31,,,percent of total billed charges,,,,,,,,,31.03,,,fee schedule,,,,,,,,,,,,,,,26.9,,,fee schedule,,,35.86,,,fee schedule,,,20.17,,,fee schedule,,,32.79,,,fee schedule,,,25194.31,,,percent of total billed charges,,,25194.31,,,percent of total billed charges,,,25194.31,,,percent of total billed charges,,,,,,,,,17663.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12597.16,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,14844.49,,,percent of total billed charges,,
NIVOLUMAB 240MG/24ML VIAL,2500032637,CDM,636,RC,J9299,HCPCS,3373413,NDC,9453,APC,,outpatient,facility,24,ML,25194.31,25194.31,31.01,9221.12,,,,,,,,33.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.62,,,fee schedule,,,,,,,,,9221.12,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,33.92,,,fee schedule,,,33.92,,,fee schedule,,,,,,,,,32.3,,,fee schedule,,,32.3,,,fee schedule,,,33.92,,,fee schedule,,,,,,,,,,,,,,,48.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.01,,,fee schedule,,,34.56,,,fee schedule,,,33.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,33.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,40.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,40.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,32.3,,,fee schedule,,,32.3,,,fee schedule,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,32.3,,,fee schedule,,,33.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,33.59,,,fee schedule,,,32.3,,,fee schedule,,,,,,,,,32.3,,,fee schedule,,,,,,,,,32.3,,,fee schedule,,,33.92,,,fee schedule,,,,,,,,
NIVOLUMAB 240MG/24ML VIAL,2500032637,CDM,636,RC,J9299,HCPCS,3373413,NDC,463,EAPG,,outpatient,facility,24,ML,25194.31,25194.31,32.3,48.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.77,,,fee schedule,,,32.3,,,fee schedule,,,43.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,32.3,,,fee schedule,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,32.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AQUAPHOR OINT 50 GM,2500032662,CDM,637,RC,7214045231,NDC,,,,,,inpatient,facility,50,UN,26.63,26.63,2.13,26.63,,,,,,,,,,,,,,26.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.63,,,percent of total billed charges,,,,,,,,,26.63,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.98,,,percent of total billed charges,,,,,,,,,,,,,,,26.63,,,percent of total billed charges,,,22.64,,,percent of total billed charges,,,,,,,,,,,,,,,26.63,,,percent of total billed charges,,,14.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,26.63,,,percent of total billed charges,,,,,,,,,,,,,,,2.13,,,percent of total billed charges,,,26.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.69,,,percent of total billed charges,,
AQUAPHOR OINT 50 GM,2500032662,CDM,637,RC,7214045231,NDC,,,,,,outpatient,facility,50,UN,26.63,26.63,2.13,548.68,,18.88,,,percent of total billed charges,,,6.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,26.63,,,percent of total billed charges,,,16.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,18.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,18.72,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,26.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.75,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,26.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,26.63,,,fee schedule,,,26.63,,,percent of total billed charges,,,,,,,,,26.63,,,percent of total billed charges,,,16.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.97,,,percent of total billed charges,,,,,,,,,,,,,,,14.38,,,percent of total billed charges,,,13.85,,,percent of total billed charges,,,14.65,,,percent of total billed charges,,,,,,,,,15.71,,,percent of total billed charges,,,548.68,,,per diem,,,26.63,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,26.63,,,percent of total billed charges,,,22.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.14,,,percent of total billed charges,,,26.63,,,percent of total billed charges,,,26.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.96,,,percent of total billed charges,,,21.55,,,percent of total billed charges,,,,,,,,,,,,,,,10.65,,,percent of total billed charges,,,,,,,,,9.85,,,percent of total billed charges,,,9.85,,,percent of total billed charges,,,,,,,,,26.63,,,percent of total billed charges,,,26.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,26.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.13,,,percent of total billed charges,,,26.63,,,percent of total billed charges,,,,,,,,,,,,,,,26.63,,,percent of total billed charges,,,26.63,,,percent of total billed charges,,,,,,,,,24.77,,,percent of total billed charges,,,,,,,,,,,,,,,24.77,,,percent of total billed charges,,,24.77,,,percent of total billed charges,,,24.77,,,percent of total billed charges,,,19.97,,,percent of total billed charges,,,26.63,,,percent of total billed charges,,,26.63,,,percent of total billed charges,,,26.63,,,percent of total billed charges,,,,,,,,,18.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.31,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15.69,,,percent of total billed charges,,
AQUAPHOR OINT 50 GM,2500032662,CDM,637,RC,7214045231,NDC,999,EAPG,,,,outpatient,facility,50,UN,26.63,26.63,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LEUPROLIDE ACET 7.5 MG,2500032671,CDM,636,RC,J9217,HCPCS,6293575375,NDC,,,,inpatient,facility,7.5,UN,1490.58,1490.58,119.25,1490.58,,,,,,,,,,,,,,1490.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1490.58,,,percent of total billed charges,,,,,,,,,1490.58,,,percent of total billed charges,,,761.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1269.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.35,,,percent of total billed charges,,,,,,,,,,,,,,,1490.58,,,percent of total billed charges,,,1266.99,,,percent of total billed charges,,,,,,,,,,,,,,,1490.58,,,percent of total billed charges,,,791.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,596.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1490.58,,,percent of total billed charges,,,,,,,,,,,,,,,119.25,,,percent of total billed charges,,,1490.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1490.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.25,,,percent of total billed charges,,
LEUPROLIDE ACET 7.5 MG,2500032671,CDM,636,RC,J9217,HCPCS,6293575375,NDC,,,,outpatient,facility,7.5,UN,1490.58,1490.58,113.61,1490.58,,185.66,,,fee schedule,,,,,,,,,1490.58,,,percent of total billed charges,,,234.34,,,fee schedule,,,221.7,,,fee schedule,,,,,,,,,221.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1490.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,230.11,,,fee schedule,,,1490.58,,,fee schedule,,,1490.58,,,percent of total billed charges,,,,,,,,,1490.58,,,percent of total billed charges,,,913.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1062.04,,,percent of total billed charges,,,,,,,,,,,,,,,181.3,,,fee schedule,,,181.3,,,fee schedule,,,181.3,,,fee schedule,,,,,,,,,879.44,,,percent of total billed charges,,,548.68,,,per diem,,,1490.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1490.58,,,percent of total billed charges,,,1266.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,791.65,,,percent of total billed charges,,,1490.58,,,percent of total billed charges,,,1490.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1005.55,,,percent of total billed charges,,,1206.18,,,percent of total billed charges,,,,,,,,,,,,,,,596.23,,,percent of total billed charges,,,,,,,,,409.02,,,fee schedule,,,294.32,,,fee schedule,,,,,,,,,1490.58,,,percent of total billed charges,,,,,,,,,,,,,,,119.25,,,percent of total billed charges,,,1490.58,,,percent of total billed charges,,,,,,,,,,,,,,,1490.58,,,percent of total billed charges,,,1490.58,,,percent of total billed charges,,,,,,,,,174.79,,,fee schedule,,,,,,,,,,,,,,,151.49,,,fee schedule,,,201.99,,,fee schedule,,,113.61,,,fee schedule,,,187.35,,,fee schedule,,,1490.58,,,percent of total billed charges,,,1490.58,,,percent of total billed charges,,,1490.58,,,percent of total billed charges,,,,,,,,,1045.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,745.29,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,878.25,,,percent of total billed charges,,
LEUPROLIDE ACET 7.5 MG,2500032671,CDM,636,RC,J9217,HCPCS,6293575375,NDC,9217,APC,,outpatient,facility,7.5,UN,1490.58,1490.58,173.56,545.55,,,,,,,,186.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.6,,,fee schedule,,,,,,,,,545.55,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,189.83,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,180.79,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,,,,,,,,271.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.56,,,fee schedule,,,193.45,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,180.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,188.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,225.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,225.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,180.79,,,fee schedule,,,180.79,,,fee schedule,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,186.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.79,,,fee schedule,,,,,,,,,,,,,,,188.02,,,fee schedule,,,180.79,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,,,,,,,180.79,,,fee schedule,,,189.83,,,fee schedule,,,,,,,,
LEUPROLIDE ACET 7.5 MG,2500032671,CDM,636,RC,J9217,HCPCS,6293575375,NDC,434,EAPG,,outpatient,facility,7.5,UN,1490.58,1490.58,380.24,574.16,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,574.16,,,fee schedule,,,380.24,,,fee schedule,,,510.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,380.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,380.24,,,fee schedule,,,380.24,,,fee schedule,,,380.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,380.24,,,fee schedule,,,,,,,,,,,,,,,380.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CARFILZOMIB INJ 10 MG,2500032676,CDM,636,RC,J9047,HCPCS,7607510301,NDC,,,,inpatient,facility,10,UN,1801.33,1801.33,144.11,1801.33,,,,,,,,,,,,,,1801.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1801.33,,,percent of total billed charges,,,,,,,,,1801.33,,,percent of total billed charges,,,919.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1534.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1080.8,,,percent of total billed charges,,,,,,,,,,,,,,,1801.33,,,percent of total billed charges,,,1531.13,,,percent of total billed charges,,,,,,,,,,,,,,,1801.33,,,percent of total billed charges,,,956.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1801.33,,,percent of total billed charges,,,,,,,,,,,,,,,144.11,,,percent of total billed charges,,,1801.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1801.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1061.34,,,percent of total billed charges,,
CARFILZOMIB INJ 10 MG,2500032676,CDM,636,RC,J9047,HCPCS,7607510301,NDC,,,,outpatient,facility,10,UN,1801.33,1801.33,30.05,1801.33,,47.18,,,fee schedule,,,,,,,,,1801.33,,,percent of total billed charges,,,64.42,,,fee schedule,,,60.95,,,fee schedule,,,,,,,,,60.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1801.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,33.39,,,fee schedule,,,1801.33,,,fee schedule,,,1801.33,,,percent of total billed charges,,,,,,,,,1801.33,,,percent of total billed charges,,,1104.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1283.45,,,percent of total billed charges,,,,,,,,,,,,,,,47.09,,,fee schedule,,,47.09,,,fee schedule,,,47.09,,,fee schedule,,,,,,,,,1062.78,,,percent of total billed charges,,,548.68,,,per diem,,,1801.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1801.33,,,percent of total billed charges,,,1531.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.69,,,percent of total billed charges,,,1801.33,,,percent of total billed charges,,,1801.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1215.18,,,percent of total billed charges,,,1457.64,,,percent of total billed charges,,,,,,,,,,,,,,,720.53,,,percent of total billed charges,,,,,,,,,108.18,,,fee schedule,,,77.85,,,fee schedule,,,,,,,,,1801.33,,,percent of total billed charges,,,,,,,,,,,,,,,144.11,,,percent of total billed charges,,,1801.33,,,percent of total billed charges,,,,,,,,,,,,,,,1801.33,,,percent of total billed charges,,,1801.33,,,percent of total billed charges,,,,,,,,,46.23,,,fee schedule,,,,,,,,,,,,,,,40.07,,,fee schedule,,,53.43,,,fee schedule,,,30.05,,,fee schedule,,,51.5,,,fee schedule,,,1801.33,,,percent of total billed charges,,,1801.33,,,percent of total billed charges,,,1801.33,,,percent of total billed charges,,,,,,,,,1262.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,900.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,1061.34,,,percent of total billed charges,,
CARFILZOMIB INJ 10 MG,2500032676,CDM,636,RC,J9047,HCPCS,7607510301,NDC,9295,APC,,outpatient,facility,10,UN,1801.33,1801.33,49.89,659.29,,,,,,,,53.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.49,,,fee schedule,,,,,,,,,659.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,,,,,,,54.57,,,fee schedule,,,54.57,,,fee schedule,,,,,,,,,51.97,,,fee schedule,,,51.97,,,fee schedule,,,54.57,,,fee schedule,,,,,,,,,,,,,,,77.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.89,,,fee schedule,,,55.61,,,fee schedule,,,54.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,51.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,54.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,64.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,64.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,51.97,,,fee schedule,,,51.97,,,fee schedule,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,51.97,,,fee schedule,,,53.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,,,,,,,54.05,,,fee schedule,,,51.97,,,fee schedule,,,,,,,,,51.97,,,fee schedule,,,,,,,,,51.97,,,fee schedule,,,54.57,,,fee schedule,,,,,,,,
CARFILZOMIB INJ 10 MG,2500032676,CDM,636,RC,J9047,HCPCS,7607510301,NDC,460,EAPG,,outpatient,facility,10,UN,1801.33,1801.33,51.97,78.47,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.47,,,fee schedule,,,51.97,,,fee schedule,,,69.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,51.97,,,fee schedule,,,51.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,,,,,,,51.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BIKTARVY TAB,2500032681,CDM,637,RC,6195825011,NDC,,,,,,inpatient,facility,1,UN,437.94,437.94,35.04,437.94,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,437.94,,,percent of total billed charges,,,223.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.76,,,percent of total billed charges,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,372.25,,,percent of total billed charges,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,232.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,35.04,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258.03,,,percent of total billed charges,,
BIKTARVY TAB,2500032681,CDM,637,RC,6195825011,NDC,,,,,,outpatient,facility,1,UN,437.94,437.94,35.04,548.68,,310.54,,,percent of total billed charges,,,106.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,437.94,,,percent of total billed charges,,,274.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,307.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,307.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,160.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,437.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,437.94,,,fee schedule,,,437.94,,,percent of total billed charges,,,,,,,,,437.94,,,percent of total billed charges,,,268.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,312.03,,,percent of total billed charges,,,,,,,,,,,,,,,236.49,,,percent of total billed charges,,,227.73,,,percent of total billed charges,,,240.87,,,percent of total billed charges,,,,,,,,,258.38,,,percent of total billed charges,,,548.68,,,per diem,,,437.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,437.94,,,percent of total billed charges,,,372.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.59,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,295.43,,,percent of total billed charges,,,354.38,,,percent of total billed charges,,,,,,,,,,,,,,,175.18,,,percent of total billed charges,,,,,,,,,162.04,,,percent of total billed charges,,,162.04,,,percent of total billed charges,,,,,,,,,437.94,,,percent of total billed charges,,,437.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,437.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.04,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,,,,,,,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,407.37,,,percent of total billed charges,,,,,,,,,,,,,,,407.37,,,percent of total billed charges,,,407.37,,,percent of total billed charges,,,407.37,,,percent of total billed charges,,,328.45,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,437.94,,,percent of total billed charges,,,,,,,,,307.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.97,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,258.03,,,percent of total billed charges,,
BIKTARVY TAB,2500032681,CDM,637,RC,6195825011,NDC,999,EAPG,,,,outpatient,facility,1,UN,437.94,437.94,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
BUPIVACAINE PF 0.5  450 ML,2500032691,CDM,250,RC,7101914206,NDC,,,,,,inpatient,facility,450,UN,1047.82,1047.82,83.83,1047.82,,,,,,,,,,,,,,1047.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1047.82,,,percent of total billed charges,,,,,,,,,1047.82,,,percent of total billed charges,,,535.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,892.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,628.69,,,percent of total billed charges,,,,,,,,,,,,,,,1047.82,,,percent of total billed charges,,,890.65,,,percent of total billed charges,,,,,,,,,,,,,,,1047.82,,,percent of total billed charges,,,556.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1047.82,,,percent of total billed charges,,,,,,,,,,,,,,,83.83,,,percent of total billed charges,,,1047.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1047.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,617.38,,,percent of total billed charges,,
BUPIVACAINE PF 0.5  450 ML,2500032691,CDM,250,RC,7101914206,NDC,,,,,,outpatient,facility,450,UN,1047.82,1047.82,83.83,1047.82,,743.01,,,percent of total billed charges,,,255.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,1047.82,,,percent of total billed charges,,,656.67,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,736.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,736.62,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,1047.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,383.5,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1047.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1047.82,,,fee schedule,,,1047.82,,,percent of total billed charges,,,,,,,,,1047.82,,,percent of total billed charges,,,642.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,618.21,,,percent of total billed charges,,,548.68,,,per diem,,,1047.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1047.82,,,percent of total billed charges,,,890.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,556.5,,,percent of total billed charges,,,1047.82,,,percent of total billed charges,,,1047.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,706.86,,,percent of total billed charges,,,847.9,,,percent of total billed charges,,,,,,,,,,,,,,,419.13,,,percent of total billed charges,,,,,,,,,419.13,,,percent of total billed charges,,,419.13,,,percent of total billed charges,,,,,,,,,1047.82,,,percent of total billed charges,,,1047.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,1047.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,83.83,,,percent of total billed charges,,,1047.82,,,percent of total billed charges,,,,,,,,,,,,,,,1047.82,,,percent of total billed charges,,,1047.82,,,percent of total billed charges,,,,,,,,,419.13,,,percent of total billed charges,,,,,,,,,,,,,,,419.13,,,percent of total billed charges,,,419.13,,,percent of total billed charges,,,419.13,,,percent of total billed charges,,,785.87,,,percent of total billed charges,,,1047.82,,,percent of total billed charges,,,1047.82,,,percent of total billed charges,,,1047.82,,,percent of total billed charges,,,,,,,,,734.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.91,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,617.38,,,percent of total billed charges,,
BUPIVACAINE PF 0.5  450 ML,2500032691,CDM,250,RC,7101914206,NDC,999,EAPG,,,,outpatient,facility,450,UN,1047.82,1047.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
TDT VACCINE- ADULT- SL,2500032704,CDM,636,RC,90714,CPT,1353313101,NDC,,,,inpatient,facility,0.5,UN,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
TDT VACCINE- ADULT- SL,2500032704,CDM,636,RC,90714,CPT,1353313101,NDC,,,,outpatient,facility,0.5,UN,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,service not payable,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,0.01,,,percent of total billed charges,,,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
TDT VACCINE- ADULT- SL,2500032704,CDM,636,RC,90714,CPT,1353313101,NDC,414,EAPG,,outpatient,facility,0.5,UN,0.01,0.01,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLYCERIN ADULT SUPP,2500032707,CDM,637,RC,5898041012,NDC,,,,,,inpatient,facility,1,UN,0.66,0.66,0.05,0.66,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.05,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.39,,,percent of total billed charges,,
GLYCERIN ADULT SUPP,2500032707,CDM,637,RC,5898041012,NDC,,,,,,outpatient,facility,1,UN,0.66,0.66,0.05,548.68,,0.47,,,percent of total billed charges,,,0.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,0.66,,,percent of total billed charges,,,0.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,0.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,0.46,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,0.24,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.66,,,fee schedule,,,0.66,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,0.36,,,percent of total billed charges,,,0.34,,,percent of total billed charges,,,0.36,,,percent of total billed charges,,,,,,,,,0.39,,,percent of total billed charges,,,548.68,,,per diem,,,0.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.66,,,percent of total billed charges,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.35,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,0.53,,,percent of total billed charges,,,,,,,,,,,,,,,0.26,,,percent of total billed charges,,,,,,,,,0.24,,,percent of total billed charges,,,0.24,,,percent of total billed charges,,,,,,,,,0.66,,,percent of total billed charges,,,0.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.05,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,,,,,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.61,,,percent of total billed charges,,,0.49,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,0.66,,,percent of total billed charges,,,,,,,,,0.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.33,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.39,,,percent of total billed charges,,
GLYCERIN ADULT SUPP,2500032707,CDM,637,RC,5898041012,NDC,999,EAPG,,,,outpatient,facility,1,UN,0.66,0.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LANREOTIDE 120 MG/0.5ML SYR,2500032714,CDM,636,RC,J1930,HCPCS,6909787067,NDC,,,,inpatient,facility,0.5,ML,30450.19,30450.19,2436.02,30450.19,,,,,,,,,,,,,,30450.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30450.19,,,percent of total billed charges,,,,,,,,,30450.19,,,percent of total billed charges,,,15547.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25934.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18270.11,,,percent of total billed charges,,,,,,,,,,,,,,,30450.19,,,percent of total billed charges,,,25882.66,,,percent of total billed charges,,,,,,,,,,,,,,,30450.19,,,percent of total billed charges,,,16172.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12180.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,30450.19,,,percent of total billed charges,,,,,,,,,,,,,,,2436.02,,,percent of total billed charges,,,30450.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30450.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17941.25,,,percent of total billed charges,,
LANREOTIDE 120 MG/0.5ML SYR,2500032714,CDM,636,RC,J1930,HCPCS,6909787067,NDC,,,,outpatient,facility,0.5,ML,30450.19,30450.19,43.46,30450.19,,21592.23,,,percent of total billed charges,,,,,,,,,30450.19,,,percent of total billed charges,,,64.94,,,fee schedule,,,61.44,,,fee schedule,,,,,,,,,61.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,30450.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,30450.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,30450.19,,,fee schedule,,,30450.19,,,percent of total billed charges,,,,,,,,,30450.19,,,percent of total billed charges,,,18662.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21695.76,,,percent of total billed charges,,,,,,,,,,,,,,,48.44,,,fee schedule,,,48.44,,,fee schedule,,,48.44,,,fee schedule,,,,,,,,,17965.61,,,percent of total billed charges,,,548.68,,,per diem,,,30450.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,30450.19,,,percent of total billed charges,,,25882.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16172.1,,,percent of total billed charges,,,30450.19,,,percent of total billed charges,,,30450.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20541.7,,,percent of total billed charges,,,24640.29,,,percent of total billed charges,,,,,,,,,,,,,,,12180.08,,,percent of total billed charges,,,,,,,,,156.46,,,fee schedule,,,112.59,,,fee schedule,,,,,,,,,30450.19,,,percent of total billed charges,,,,,,,,,,,,,,,2436.02,,,percent of total billed charges,,,30450.19,,,percent of total billed charges,,,,,,,,,,,,,,,30450.19,,,percent of total billed charges,,,30450.19,,,percent of total billed charges,,,,,,,,,66.86,,,fee schedule,,,,,,,,,,,,,,,57.95,,,fee schedule,,,77.27,,,fee schedule,,,43.46,,,fee schedule,,,51.91,,,fee schedule,,,30450.19,,,percent of total billed charges,,,30450.19,,,percent of total billed charges,,,30450.19,,,percent of total billed charges,,,,,,,,,21348.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15225.09,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,17941.25,,,percent of total billed charges,,
LANREOTIDE 120 MG/0.5ML SYR,2500032714,CDM,636,RC,J1930,HCPCS,6909787067,NDC,9237,APC,,outpatient,facility,0.5,ML,30450.19,30450.19,43.18,11144.77,,,,,,,,46.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,44.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.43,,,fee schedule,,,,,,,,,11144.77,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,44.98,,,fee schedule,,,,,,,,,,,,,,,47.23,,,fee schedule,,,47.23,,,fee schedule,,,,,,,,,44.98,,,fee schedule,,,44.98,,,fee schedule,,,47.23,,,fee schedule,,,,,,,,,,,,,,,67.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,44.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.18,,,fee schedule,,,48.13,,,fee schedule,,,47.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.98,,,fee schedule,,,44.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,44.98,,,fee schedule,,,,,,,,,56.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,56.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,44.98,,,fee schedule,,,44.98,,,fee schedule,,,,,,,,,,,,,,,44.98,,,fee schedule,,,,,,,,,44.98,,,fee schedule,,,46.33,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.98,,,fee schedule,,,,,,,,,,,,,,,46.78,,,fee schedule,,,44.98,,,fee schedule,,,,,,,,,44.98,,,fee schedule,,,,,,,,,44.98,,,fee schedule,,,47.23,,,fee schedule,,,,,,,,
LANREOTIDE 120 MG/0.5ML SYR,2500032714,CDM,636,RC,J1930,HCPCS,6909787067,NDC,463,EAPG,,outpatient,facility,0.5,ML,30450.19,30450.19,7053.67,10651.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10651.04,,,fee schedule,,,7053.67,,,fee schedule,,,9468.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEGARELIX 80 MG INJ,2500032718,CDM,636,RC,J9155,HCPCS,5556683031,NDC,,,,inpatient,facility,80,GR,1611.89,1611.89,128.95,1611.89,,,,,,,,,,,,,,1611.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1611.89,,,percent of total billed charges,,,,,,,,,1611.89,,,percent of total billed charges,,,823.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1372.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,967.13,,,percent of total billed charges,,,,,,,,,,,,,,,1611.89,,,percent of total billed charges,,,1370.11,,,percent of total billed charges,,,,,,,,,,,,,,,1611.89,,,percent of total billed charges,,,856.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,644.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1611.89,,,percent of total billed charges,,,,,,,,,,,,,,,128.95,,,percent of total billed charges,,,1611.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1611.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,949.73,,,percent of total billed charges,,
DEGARELIX 80 MG INJ,2500032718,CDM,636,RC,J9155,HCPCS,5556683031,NDC,,,,outpatient,facility,80,GR,1611.89,1611.89,2.78,1611.89,,1142.99,,,percent of total billed charges,,,,,,,,,1611.89,,,percent of total billed charges,,,5.54,,,fee schedule,,,5.24,,,fee schedule,,,,,,,,,5.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1611.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3.02,,,fee schedule,,,1611.89,,,fee schedule,,,1611.89,,,percent of total billed charges,,,,,,,,,1611.89,,,percent of total billed charges,,,987.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1148.47,,,percent of total billed charges,,,,,,,,,,,,,,,4.19,,,fee schedule,,,4.19,,,fee schedule,,,4.19,,,fee schedule,,,,,,,,,951.02,,,percent of total billed charges,,,548.68,,,per diem,,,1611.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1611.89,,,percent of total billed charges,,,1370.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,856.07,,,percent of total billed charges,,,1611.89,,,percent of total billed charges,,,1611.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1087.38,,,percent of total billed charges,,,1304.34,,,percent of total billed charges,,,,,,,,,,,,,,,644.76,,,percent of total billed charges,,,,,,,,,10.02,,,fee schedule,,,7.21,,,fee schedule,,,,,,,,,1611.89,,,percent of total billed charges,,,,,,,,,,,,,,,128.95,,,percent of total billed charges,,,1611.89,,,percent of total billed charges,,,,,,,,,,,,,,,1611.89,,,percent of total billed charges,,,1611.89,,,percent of total billed charges,,,,,,,,,4.28,,,fee schedule,,,,,,,,,,,,,,,3.71,,,fee schedule,,,4.95,,,fee schedule,,,2.78,,,fee schedule,,,4.43,,,fee schedule,,,1611.89,,,percent of total billed charges,,,1611.89,,,percent of total billed charges,,,1611.89,,,percent of total billed charges,,,,,,,,,1130.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,805.95,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,949.73,,,percent of total billed charges,,
DEGARELIX 80 MG INJ,2500032718,CDM,636,RC,J9155,HCPCS,5556683031,NDC,1296,APC,,outpatient,facility,80,GR,1611.89,1611.89,4.11,589.95,,,,,,,,4.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,4.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.32,,,fee schedule,,,,,,,,,589.95,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,4.28,,,fee schedule,,,,,,,,,,,,,,,4.49,,,fee schedule,,,4.49,,,fee schedule,,,,,,,,,4.28,,,fee schedule,,,4.28,,,fee schedule,,,4.49,,,fee schedule,,,,,,,,,,,,,,,6.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,4.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.11,,,fee schedule,,,4.58,,,fee schedule,,,4.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.28,,,fee schedule,,,4.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,4.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4.28,,,fee schedule,,,,,,,,,5.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,4.28,,,fee schedule,,,4.28,,,fee schedule,,,,,,,,,,,,,,,4.28,,,fee schedule,,,,,,,,,4.28,,,fee schedule,,,4.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.28,,,fee schedule,,,,,,,,,,,,,,,4.45,,,fee schedule,,,4.28,,,fee schedule,,,,,,,,,4.28,,,fee schedule,,,,,,,,,4.28,,,fee schedule,,,4.49,,,fee schedule,,,,,,,,
DEGARELIX 80 MG INJ,2500032718,CDM,636,RC,J9155,HCPCS,5556683031,NDC,433,EAPG,,outpatient,facility,80,GR,1611.89,1611.89,349.48,527.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,527.71,,,fee schedule,,,349.48,,,fee schedule,,,469.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.48,,,fee schedule,,,349.48,,,fee schedule,,,349.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,349.48,,,fee schedule,,,,,,,,,,,,,,,349.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ELOTUZUMAB 300 MG INJ,2500032730,CDM,636,RC,J9176,HCPCS,3229111,NDC,,,,inpatient,facility,300,UN,7362.43,7362.43,588.99,7362.43,,,,,,,,,,,,,,7362.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7362.43,,,percent of total billed charges,,,,,,,,,7362.43,,,percent of total billed charges,,,3759.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6270.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4417.46,,,percent of total billed charges,,,,,,,,,,,,,,,7362.43,,,percent of total billed charges,,,6258.07,,,percent of total billed charges,,,,,,,,,,,,,,,7362.43,,,percent of total billed charges,,,3910.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2944.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,7362.43,,,percent of total billed charges,,,,,,,,,,,,,,,588.99,,,percent of total billed charges,,,7362.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7362.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4337.94,,,percent of total billed charges,,
ELOTUZUMAB 300 MG INJ,2500032730,CDM,636,RC,J9176,HCPCS,3229111,NDC,,,,outpatient,facility,300,UN,7362.43,7362.43,4.75,7362.43,,7.4,,,fee schedule,,,,,,,,,7362.43,,,percent of total billed charges,,,9.83,,,fee schedule,,,9.3,,,fee schedule,,,,,,,,,9.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7362.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,7362.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,7362.43,,,fee schedule,,,7362.43,,,percent of total billed charges,,,,,,,,,7362.43,,,percent of total billed charges,,,4512.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5245.73,,,percent of total billed charges,,,,,,,,,,,,,,,7.38,,,fee schedule,,,7.38,,,fee schedule,,,7.38,,,fee schedule,,,,,,,,,4343.83,,,percent of total billed charges,,,548.68,,,per diem,,,7362.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,7362.43,,,percent of total billed charges,,,6258.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3910.19,,,percent of total billed charges,,,7362.43,,,percent of total billed charges,,,7362.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4966.7,,,percent of total billed charges,,,5957.68,,,percent of total billed charges,,,,,,,,,,,,,,,2944.97,,,percent of total billed charges,,,,,,,,,17.08,,,fee schedule,,,12.29,,,fee schedule,,,,,,,,,7362.43,,,percent of total billed charges,,,,,,,,,,,,,,,588.99,,,percent of total billed charges,,,7362.43,,,percent of total billed charges,,,,,,,,,,,,,,,7362.43,,,percent of total billed charges,,,7362.43,,,percent of total billed charges,,,,,,,,,7.3,,,fee schedule,,,,,,,,,,,,,,,6.32,,,fee schedule,,,8.43,,,fee schedule,,,4.75,,,fee schedule,,,7.85,,,fee schedule,,,7362.43,,,percent of total billed charges,,,7362.43,,,percent of total billed charges,,,7362.43,,,percent of total billed charges,,,,,,,,,5161.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3681.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4337.94,,,percent of total billed charges,,
ELOTUZUMAB 300 MG INJ,2500032730,CDM,636,RC,J9176,HCPCS,3229111,NDC,9477,APC,,outpatient,facility,300,UN,7362.43,7362.43,7.41,2694.65,,,,,,,,7.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,7.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.8,,,fee schedule,,,,,,,,,2694.65,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,fee schedule,,,,,,,,,,,,,,,8.11,,,fee schedule,,,8.11,,,fee schedule,,,,,,,,,7.72,,,fee schedule,,,7.72,,,fee schedule,,,8.11,,,fee schedule,,,,,,,,,,,,,,,11.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,7.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.41,,,fee schedule,,,8.26,,,fee schedule,,,8.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,fee schedule,,,7.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,8.03,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,fee schedule,,,,,,,,,9.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,7.72,,,fee schedule,,,7.72,,,fee schedule,,,,,,,,,,,,,,,7.72,,,fee schedule,,,,,,,,,7.72,,,fee schedule,,,7.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,fee schedule,,,,,,,,,,,,,,,8.03,,,fee schedule,,,7.72,,,fee schedule,,,,,,,,,7.72,,,fee schedule,,,,,,,,,7.72,,,fee schedule,,,8.11,,,fee schedule,,,,,,,,
ELOTUZUMAB 300 MG INJ,2500032730,CDM,636,RC,J9176,HCPCS,3229111,NDC,462,EAPG,,outpatient,facility,300,UN,7362.43,7362.43,4530.01,6840.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6840.32,,,fee schedule,,,4530.01,,,fee schedule,,,6081.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ELOTUZUMAB 400 MG INJ,2500032731,CDM,636,RC,J9176,HCPCS,3452211,NDC,,,,inpatient,facility,400,UN,9816.48,9816.48,785.32,9816.48,,,,,,,,,,,,,,9816.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9816.48,,,percent of total billed charges,,,,,,,,,9816.48,,,percent of total billed charges,,,5012.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8360.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5889.89,,,percent of total billed charges,,,,,,,,,,,,,,,9816.48,,,percent of total billed charges,,,8344.01,,,percent of total billed charges,,,,,,,,,,,,,,,9816.48,,,percent of total billed charges,,,5213.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3926.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,9816.48,,,percent of total billed charges,,,,,,,,,,,,,,,785.32,,,percent of total billed charges,,,9816.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9816.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5783.87,,,percent of total billed charges,,
ELOTUZUMAB 400 MG INJ,2500032731,CDM,636,RC,J9176,HCPCS,3452211,NDC,,,,outpatient,facility,400,UN,9816.48,9816.48,4.75,9816.48,,7.4,,,fee schedule,,,,,,,,,9816.48,,,percent of total billed charges,,,9.83,,,fee schedule,,,9.3,,,fee schedule,,,,,,,,,9.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,9816.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,9816.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,9816.48,,,fee schedule,,,9816.48,,,percent of total billed charges,,,,,,,,,9816.48,,,percent of total billed charges,,,6016.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6994.24,,,percent of total billed charges,,,,,,,,,,,,,,,7.38,,,fee schedule,,,7.38,,,fee schedule,,,7.38,,,fee schedule,,,,,,,,,5791.72,,,percent of total billed charges,,,548.68,,,per diem,,,9816.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,9816.48,,,percent of total billed charges,,,8344.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5213.53,,,percent of total billed charges,,,9816.48,,,percent of total billed charges,,,9816.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6622.2,,,percent of total billed charges,,,7943.5,,,percent of total billed charges,,,,,,,,,,,,,,,3926.59,,,percent of total billed charges,,,,,,,,,17.08,,,fee schedule,,,12.29,,,fee schedule,,,,,,,,,9816.48,,,percent of total billed charges,,,,,,,,,,,,,,,785.32,,,percent of total billed charges,,,9816.48,,,percent of total billed charges,,,,,,,,,,,,,,,9816.48,,,percent of total billed charges,,,9816.48,,,percent of total billed charges,,,,,,,,,7.3,,,fee schedule,,,,,,,,,,,,,,,6.32,,,fee schedule,,,8.43,,,fee schedule,,,4.75,,,fee schedule,,,7.85,,,fee schedule,,,9816.48,,,percent of total billed charges,,,9816.48,,,percent of total billed charges,,,9816.48,,,percent of total billed charges,,,,,,,,,6882.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4908.24,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,5783.87,,,percent of total billed charges,,
ELOTUZUMAB 400 MG INJ,2500032731,CDM,636,RC,J9176,HCPCS,3452211,NDC,9477,APC,,outpatient,facility,400,UN,9816.48,9816.48,7.41,3592.83,,,,,,,,7.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,7.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.8,,,fee schedule,,,,,,,,,3592.83,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,fee schedule,,,,,,,,,,,,,,,8.11,,,fee schedule,,,8.11,,,fee schedule,,,,,,,,,7.72,,,fee schedule,,,7.72,,,fee schedule,,,8.11,,,fee schedule,,,,,,,,,,,,,,,11.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,7.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.41,,,fee schedule,,,8.26,,,fee schedule,,,8.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,fee schedule,,,7.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,8.03,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,fee schedule,,,,,,,,,9.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,7.72,,,fee schedule,,,7.72,,,fee schedule,,,,,,,,,,,,,,,7.72,,,fee schedule,,,,,,,,,7.72,,,fee schedule,,,7.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.72,,,fee schedule,,,,,,,,,,,,,,,8.03,,,fee schedule,,,7.72,,,fee schedule,,,,,,,,,7.72,,,fee schedule,,,,,,,,,7.72,,,fee schedule,,,8.11,,,fee schedule,,,,,,,,
ELOTUZUMAB 400 MG INJ,2500032731,CDM,636,RC,J9176,HCPCS,3452211,NDC,462,EAPG,,outpatient,facility,400,UN,9816.48,9816.48,4530.01,6840.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6840.32,,,fee schedule,,,4530.01,,,fee schedule,,,6081.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,4530.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
PEGFILGRSTM-JMDB INJ 6MG/0.6ML,2500032734,CDM,636,RC,Q5108,HCPCS,8325700541,NDC,,,,inpatient,facility,0.6,ML,6888.75,6888.75,551.1,6888.75,,,,,,,,,,,,,,6888.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6888.75,,,percent of total billed charges,,,,,,,,,6888.75,,,percent of total billed charges,,,3517.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5867.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4133.25,,,percent of total billed charges,,,,,,,,,,,,,,,6888.75,,,percent of total billed charges,,,5855.44,,,percent of total billed charges,,,,,,,,,,,,,,,6888.75,,,percent of total billed charges,,,3658.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2755.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,6888.75,,,percent of total billed charges,,,,,,,,,,,,,,,551.1,,,percent of total billed charges,,,6888.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6888.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4058.85,,,percent of total billed charges,,
PEGFILGRSTM-JMDB INJ 6MG/0.6ML,2500032734,CDM,636,RC,Q5108,HCPCS,8325700541,NDC,,,,outpatient,facility,0.6,ML,6888.75,6888.75,96.31,6888.75,,4884.81,,,percent of total billed charges,,,,,,,,,6888.75,,,percent of total billed charges,,,191.79,,,fee schedule,,,181.45,,,fee schedule,,,,,,,,,181.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,6888.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,6888.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,6888.75,,,fee schedule,,,6888.75,,,percent of total billed charges,,,,,,,,,6888.75,,,percent of total billed charges,,,4222.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4908.23,,,percent of total billed charges,,,,,,,,,,,,,,,122.54,,,fee schedule,,,122.54,,,fee schedule,,,122.54,,,fee schedule,,,,,,,,,4064.36,,,percent of total billed charges,,,548.68,,,per diem,,,6888.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,6888.75,,,percent of total billed charges,,,5855.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3658.62,,,percent of total billed charges,,,6888.75,,,percent of total billed charges,,,6888.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4647.15,,,percent of total billed charges,,,5574.38,,,percent of total billed charges,,,,,,,,,,,,,,,2755.5,,,percent of total billed charges,,,,,,,,,346.71,,,fee schedule,,,249.48,,,fee schedule,,,,,,,,,6888.75,,,percent of total billed charges,,,,,,,,,,,,,,,551.1,,,percent of total billed charges,,,6888.75,,,percent of total billed charges,,,,,,,,,,,,,,,6888.75,,,percent of total billed charges,,,6888.75,,,percent of total billed charges,,,,,,,,,148.17,,,fee schedule,,,,,,,,,,,,,,,128.42,,,fee schedule,,,171.22,,,fee schedule,,,96.31,,,fee schedule,,,153.33,,,fee schedule,,,6888.75,,,percent of total billed charges,,,6888.75,,,percent of total billed charges,,,6888.75,,,percent of total billed charges,,,,,,,,,4829.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3444.38,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,4058.85,,,percent of total billed charges,,
PEGFILGRSTM-JMDB INJ 6MG/0.6ML,2500032734,CDM,636,RC,Q5108,HCPCS,8325700541,NDC,9173,APC,,outpatient,facility,0.6,ML,6888.75,6888.75,120.29,2521.28,,,,,,,,129.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,125.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.55,,,fee schedule,,,,,,,,,2521.28,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,125.3,,,fee schedule,,,,,,,,,,,,,,,131.56,,,fee schedule,,,131.56,,,fee schedule,,,,,,,,,125.3,,,fee schedule,,,125.3,,,fee schedule,,,131.56,,,fee schedule,,,,,,,,,,,,,,,187.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,125.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.29,,,fee schedule,,,134.07,,,fee schedule,,,131.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.3,,,fee schedule,,,125.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,130.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,125.3,,,fee schedule,,,,,,,,,156.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,156.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,125.3,,,fee schedule,,,125.3,,,fee schedule,,,,,,,,,,,,,,,125.3,,,fee schedule,,,,,,,,,125.3,,,fee schedule,,,129.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.3,,,fee schedule,,,,,,,,,,,,,,,130.31,,,fee schedule,,,125.3,,,fee schedule,,,,,,,,,125.3,,,fee schedule,,,,,,,,,125.3,,,fee schedule,,,131.56,,,fee schedule,,,,,,,,
PEGFILGRSTM-JMDB INJ 6MG/0.6ML,2500032734,CDM,636,RC,Q5108,HCPCS,8325700541,NDC,460,EAPG,,outpatient,facility,0.6,ML,6888.75,6888.75,1604.23,2422.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2422.39,,,fee schedule,,,1604.23,,,fee schedule,,,2153.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA EPBX 3000 U,2500032735,CDM,636,RC,Q5106,HCPCS,69130610,NDC,,,,inpatient,facility,1,UN,109.2,109.2,8.74,109.2,,,,,,,,,,,,,,109.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.2,,,percent of total billed charges,,,,,,,,,109.2,,,percent of total billed charges,,,55.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.52,,,percent of total billed charges,,,,,,,,,,,,,,,109.2,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,,,,,,,,,,,,,109.2,,,percent of total billed charges,,,58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,109.2,,,percent of total billed charges,,,,,,,,,,,,,,,8.74,,,percent of total billed charges,,,109.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.34,,,percent of total billed charges,,
EPOETIN ALFA EPBX 3000 U,2500032735,CDM,636,RC,Q5106,HCPCS,69130610,NDC,,,,outpatient,facility,1,UN,109.2,109.2,5.55,548.68,,77.43,,,percent of total billed charges,,,,,,,,,109.2,,,percent of total billed charges,,,8.85,,,fee schedule,,,8.37,,,fee schedule,,,,,,,,,8.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,109.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,109.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,109.2,,,fee schedule,,,109.2,,,percent of total billed charges,,,,,,,,,109.2,,,percent of total billed charges,,,66.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.81,,,percent of total billed charges,,,,,,,,,,,,,,,7.82,,,fee schedule,,,7.82,,,fee schedule,,,7.82,,,fee schedule,,,,,,,,,64.43,,,percent of total billed charges,,,548.68,,,per diem,,,109.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,109.2,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58,,,percent of total billed charges,,,109.2,,,percent of total billed charges,,,109.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.67,,,percent of total billed charges,,,88.36,,,percent of total billed charges,,,,,,,,,,,,,,,43.68,,,percent of total billed charges,,,,,,,,,19.98,,,fee schedule,,,14.37,,,fee schedule,,,,,,,,,109.2,,,percent of total billed charges,,,,,,,,,,,,,,,8.74,,,percent of total billed charges,,,109.2,,,percent of total billed charges,,,,,,,,,,,,,,,109.2,,,percent of total billed charges,,,109.2,,,percent of total billed charges,,,,,,,,,8.54,,,fee schedule,,,,,,,,,,,,,,,7.4,,,fee schedule,,,9.86,,,fee schedule,,,5.55,,,fee schedule,,,7.07,,,fee schedule,,,109.2,,,percent of total billed charges,,,109.2,,,percent of total billed charges,,,109.2,,,percent of total billed charges,,,,,,,,,76.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.6,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,64.34,,,percent of total billed charges,,
EPOETIN ALFA EPBX 3000 U,2500032735,CDM,636,RC,Q5106,HCPCS,69130610,NDC,9097,APC,,outpatient,facility,1,UN,109.2,109.2,7.17,39.97,,,,,,,,7.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.54,,,fee schedule,,,,,,,,,39.97,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.84,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,11.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.17,,,fee schedule,,,7.99,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,7.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.77,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,
EPOETIN ALFA EPBX 3000 U,2500032735,CDM,636,RC,Q5106,HCPCS,69130610,NDC,438,EAPG,,outpatient,facility,1,UN,109.2,109.2,332.92,502.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,502.71,,,fee schedule,,,332.92,,,fee schedule,,,446.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA EPBX 10000 U,2500032736,CDM,636,RC,Q5106,HCPCS,69130810,NDC,,,,inpatient,facility,1,UN,363.99,363.99,29.12,363.99,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,363.99,,,percent of total billed charges,,,185.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,310.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.39,,,percent of total billed charges,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,309.39,,,percent of total billed charges,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,193.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,29.12,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.46,,,percent of total billed charges,,
EPOETIN ALFA EPBX 10000 U,2500032736,CDM,636,RC,Q5106,HCPCS,69130810,NDC,,,,outpatient,facility,1,UN,363.99,363.99,5.55,548.68,,258.11,,,percent of total billed charges,,,,,,,,,363.99,,,percent of total billed charges,,,8.85,,,fee schedule,,,8.37,,,fee schedule,,,,,,,,,8.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,363.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,363.99,,,fee schedule,,,363.99,,,percent of total billed charges,,,,,,,,,363.99,,,percent of total billed charges,,,223.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,259.34,,,percent of total billed charges,,,,,,,,,,,,,,,7.82,,,fee schedule,,,7.82,,,fee schedule,,,7.82,,,fee schedule,,,,,,,,,214.75,,,percent of total billed charges,,,548.68,,,per diem,,,363.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,363.99,,,percent of total billed charges,,,309.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,193.32,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.55,,,percent of total billed charges,,,294.54,,,percent of total billed charges,,,,,,,,,,,,,,,145.6,,,percent of total billed charges,,,,,,,,,19.98,,,fee schedule,,,14.37,,,fee schedule,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,29.12,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,8.54,,,fee schedule,,,,,,,,,,,,,,,7.4,,,fee schedule,,,9.86,,,fee schedule,,,5.55,,,fee schedule,,,7.07,,,fee schedule,,,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,255.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,214.46,,,percent of total billed charges,,
EPOETIN ALFA EPBX 10000 U,2500032736,CDM,636,RC,Q5106,HCPCS,69130810,NDC,9097,APC,,outpatient,facility,1,UN,363.99,363.99,7.17,133.22,,,,,,,,7.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.54,,,fee schedule,,,,,,,,,133.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.84,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,11.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.17,,,fee schedule,,,7.99,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,7.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.77,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,
EPOETIN ALFA EPBX 10000 U,2500032736,CDM,636,RC,Q5106,HCPCS,69130810,NDC,438,EAPG,,outpatient,facility,1,UN,363.99,363.99,332.92,502.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,502.71,,,fee schedule,,,332.92,,,fee schedule,,,446.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA EPBX 4000 U,2500032737,CDM,636,RC,Q5106,HCPCS,69130710,NDC,,,,inpatient,facility,1,UN,145.59,145.59,11.65,145.59,,,,,,,,,,,,,,145.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.59,,,percent of total billed charges,,,,,,,,,145.59,,,percent of total billed charges,,,74.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.35,,,percent of total billed charges,,,,,,,,,,,,,,,145.59,,,percent of total billed charges,,,123.75,,,percent of total billed charges,,,,,,,,,,,,,,,145.59,,,percent of total billed charges,,,77.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,145.59,,,percent of total billed charges,,,,,,,,,,,,,,,11.65,,,percent of total billed charges,,,145.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,145.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.78,,,percent of total billed charges,,
EPOETIN ALFA EPBX 4000 U,2500032737,CDM,636,RC,Q5106,HCPCS,69130710,NDC,,,,outpatient,facility,1,UN,145.59,145.59,5.55,548.68,,103.24,,,percent of total billed charges,,,,,,,,,145.59,,,percent of total billed charges,,,8.85,,,fee schedule,,,8.37,,,fee schedule,,,,,,,,,8.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,145.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,145.59,,,fee schedule,,,145.59,,,percent of total billed charges,,,,,,,,,145.59,,,percent of total billed charges,,,89.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.73,,,percent of total billed charges,,,,,,,,,,,,,,,7.82,,,fee schedule,,,7.82,,,fee schedule,,,7.82,,,fee schedule,,,,,,,,,85.9,,,percent of total billed charges,,,548.68,,,per diem,,,145.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,145.59,,,percent of total billed charges,,,123.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.32,,,percent of total billed charges,,,145.59,,,percent of total billed charges,,,145.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.22,,,percent of total billed charges,,,117.81,,,percent of total billed charges,,,,,,,,,,,,,,,58.24,,,percent of total billed charges,,,,,,,,,19.98,,,fee schedule,,,14.37,,,fee schedule,,,,,,,,,145.59,,,percent of total billed charges,,,,,,,,,,,,,,,11.65,,,percent of total billed charges,,,145.59,,,percent of total billed charges,,,,,,,,,,,,,,,145.59,,,percent of total billed charges,,,145.59,,,percent of total billed charges,,,,,,,,,8.54,,,fee schedule,,,,,,,,,,,,,,,7.4,,,fee schedule,,,9.86,,,fee schedule,,,5.55,,,fee schedule,,,7.07,,,fee schedule,,,145.59,,,percent of total billed charges,,,145.59,,,percent of total billed charges,,,145.59,,,percent of total billed charges,,,,,,,,,102.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,85.78,,,percent of total billed charges,,
EPOETIN ALFA EPBX 4000 U,2500032737,CDM,636,RC,Q5106,HCPCS,69130710,NDC,9097,APC,,outpatient,facility,1,UN,145.59,145.59,7.17,53.29,,,,,,,,7.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.54,,,fee schedule,,,,,,,,,53.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.84,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,11.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.17,,,fee schedule,,,7.99,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,7.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.77,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,
EPOETIN ALFA EPBX 4000 U,2500032737,CDM,636,RC,Q5106,HCPCS,69130710,NDC,438,EAPG,,outpatient,facility,1,UN,145.59,145.59,332.92,502.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,502.71,,,fee schedule,,,332.92,,,fee schedule,,,446.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA EPBX 2000 U,2500032738,CDM,636,RC,Q5106,HCPCS,69130510,NDC,,,,inpatient,facility,1,UN,72.8,72.8,5.82,72.8,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,72.8,,,percent of total billed charges,,,37.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.68,,,percent of total billed charges,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,38.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,5.82,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.89,,,percent of total billed charges,,
EPOETIN ALFA EPBX 2000 U,2500032738,CDM,636,RC,Q5106,HCPCS,69130510,NDC,,,,outpatient,facility,1,UN,72.8,72.8,5.55,548.68,,51.62,,,percent of total billed charges,,,,,,,,,72.8,,,percent of total billed charges,,,8.85,,,fee schedule,,,8.37,,,fee schedule,,,,,,,,,8.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,72.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,72.8,,,fee schedule,,,72.8,,,percent of total billed charges,,,,,,,,,72.8,,,percent of total billed charges,,,44.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.87,,,percent of total billed charges,,,,,,,,,,,,,,,7.82,,,fee schedule,,,7.82,,,fee schedule,,,7.82,,,fee schedule,,,,,,,,,42.95,,,percent of total billed charges,,,548.68,,,per diem,,,72.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,72.8,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.66,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.11,,,percent of total billed charges,,,58.91,,,percent of total billed charges,,,,,,,,,,,,,,,29.12,,,percent of total billed charges,,,,,,,,,19.98,,,fee schedule,,,14.37,,,fee schedule,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,5.82,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,,,,,,,8.54,,,fee schedule,,,,,,,,,,,,,,,7.4,,,fee schedule,,,9.86,,,fee schedule,,,5.55,,,fee schedule,,,7.07,,,fee schedule,,,72.8,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,,,,,,,51.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,42.89,,,percent of total billed charges,,
EPOETIN ALFA EPBX 2000 U,2500032738,CDM,636,RC,Q5106,HCPCS,69130510,NDC,9097,APC,,outpatient,facility,1,UN,72.8,72.8,7.17,26.64,,,,,,,,7.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.54,,,fee schedule,,,,,,,,,26.64,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.84,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,11.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.17,,,fee schedule,,,7.99,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,7.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.77,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,
EPOETIN ALFA EPBX 2000 U,2500032738,CDM,636,RC,Q5106,HCPCS,69130510,NDC,438,EAPG,,outpatient,facility,1,UN,72.8,72.8,332.92,502.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,502.71,,,fee schedule,,,332.92,,,fee schedule,,,446.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA EPBX 40000 U,2500032739,CDM,636,RC,Q5106,HCPCS,69130904,NDC,,,,inpatient,facility,1,UN,1455.96,1455.96,116.48,1455.96,,,,,,,,,,,,,,1455.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1455.96,,,percent of total billed charges,,,,,,,,,1455.96,,,percent of total billed charges,,,743.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1240.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.58,,,percent of total billed charges,,,,,,,,,,,,,,,1455.96,,,percent of total billed charges,,,1237.57,,,percent of total billed charges,,,,,,,,,,,,,,,1455.96,,,percent of total billed charges,,,773.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,582.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1455.96,,,percent of total billed charges,,,,,,,,,,,,,,,116.48,,,percent of total billed charges,,,1455.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1455.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,857.85,,,percent of total billed charges,,
EPOETIN ALFA EPBX 40000 U,2500032739,CDM,636,RC,Q5106,HCPCS,69130904,NDC,,,,outpatient,facility,1,UN,1455.96,1455.96,5.55,1455.96,,1032.42,,,percent of total billed charges,,,,,,,,,1455.96,,,percent of total billed charges,,,8.85,,,fee schedule,,,8.37,,,fee schedule,,,,,,,,,8.37,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1455.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1455.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1455.96,,,fee schedule,,,1455.96,,,percent of total billed charges,,,,,,,,,1455.96,,,percent of total billed charges,,,892.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1037.37,,,percent of total billed charges,,,,,,,,,,,,,,,7.82,,,fee schedule,,,7.82,,,fee schedule,,,7.82,,,fee schedule,,,,,,,,,859.02,,,percent of total billed charges,,,548.68,,,per diem,,,1455.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1455.96,,,percent of total billed charges,,,1237.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,773.26,,,percent of total billed charges,,,1455.96,,,percent of total billed charges,,,1455.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,982.19,,,percent of total billed charges,,,1178.16,,,percent of total billed charges,,,,,,,,,,,,,,,582.38,,,percent of total billed charges,,,,,,,,,19.98,,,fee schedule,,,14.37,,,fee schedule,,,,,,,,,1455.96,,,percent of total billed charges,,,,,,,,,,,,,,,116.48,,,percent of total billed charges,,,1455.96,,,percent of total billed charges,,,,,,,,,,,,,,,1455.96,,,percent of total billed charges,,,1455.96,,,percent of total billed charges,,,,,,,,,8.54,,,fee schedule,,,,,,,,,,,,,,,7.4,,,fee schedule,,,9.86,,,fee schedule,,,5.55,,,fee schedule,,,7.07,,,fee schedule,,,1455.96,,,percent of total billed charges,,,1455.96,,,percent of total billed charges,,,1455.96,,,percent of total billed charges,,,,,,,,,1020.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,727.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,857.85,,,percent of total billed charges,,
EPOETIN ALFA EPBX 40000 U,2500032739,CDM,636,RC,Q5106,HCPCS,69130904,NDC,9097,APC,,outpatient,facility,1,UN,1455.96,1455.96,7.17,532.88,,,,,,,,7.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.54,,,fee schedule,,,,,,,,,532.88,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.84,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,11.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.17,,,fee schedule,,,7.99,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,7.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,9.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.47,,,fee schedule,,,,,,,,,,,,,,,7.77,,,fee schedule,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,,,,,,,7.47,,,fee schedule,,,7.84,,,fee schedule,,,,,,,,
EPOETIN ALFA EPBX 40000 U,2500032739,CDM,636,RC,Q5106,HCPCS,69130904,NDC,438,EAPG,,outpatient,facility,1,UN,1455.96,1455.96,332.92,502.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,502.71,,,fee schedule,,,332.92,,,fee schedule,,,446.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,332.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA EPBX 2000U ESRD,2500032747,CDM,634,RC,Q5105,HCPCS,69130510,NDC,,,,inpatient,facility,1,UN,72.8,72.8,5.82,72.8,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,72.8,,,percent of total billed charges,,,37.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.68,,,percent of total billed charges,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,38.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,5.82,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.89,,,percent of total billed charges,,
EPOETIN ALFA EPBX 2000U ESRD,2500032747,CDM,634,RC,Q5105,HCPCS,69130510,NDC,,,,outpatient,facility,1,UN,72.8,72.8,0.7,548.68,,51.62,,,percent of total billed charges,,,,,,,,,72.8,,,percent of total billed charges,,,0.88,,,fee schedule,,,0.84,,,fee schedule,,,,,,,,,0.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,72.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,72.8,,,fee schedule,,,72.8,,,percent of total billed charges,,,,,,,,,72.8,,,percent of total billed charges,,,44.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.87,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,fee schedule,,,0.78,,,fee schedule,,,0.78,,,fee schedule,,,,,,,,,42.95,,,percent of total billed charges,,,548.68,,,per diem,,,72.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,72.8,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.66,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.11,,,percent of total billed charges,,,58.91,,,percent of total billed charges,,,,,,,,,,,,,,,29.12,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,5.82,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.7,,,fee schedule,,,72.8,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,,,,,,,51.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,42.89,,,percent of total billed charges,,
EPOETIN ALFA EPBX 2000U ESRD,2500032747,CDM,634,RC,Q5105,HCPCS,69130510,NDC,9096,APC,,outpatient,facility,1,UN,72.8,72.8,0.72,26.64,,,,,,,,0.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,fee schedule,,,,,,,,,26.64,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.79,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,,,,,,,1.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,fee schedule,,,0.8,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,0.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,0.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.78,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,
EPOETIN ALFA EPBX 2000U ESRD,2500032747,CDM,634,RC,Q5105,HCPCS,69130510,NDC,436,EAPG,,outpatient,facility,1,UN,72.8,72.8,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA EPBX 3000U ESRD,2500032748,CDM,634,RC,Q5105,HCPCS,69130610,NDC,,,,inpatient,facility,1,UN,109.19,109.19,8.74,109.19,,,,,,,,,,,,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.19,,,percent of total billed charges,,,,,,,,,109.19,,,percent of total billed charges,,,55.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.51,,,percent of total billed charges,,,,,,,,,,,,,,,109.19,,,percent of total billed charges,,,92.81,,,percent of total billed charges,,,,,,,,,,,,,,,109.19,,,percent of total billed charges,,,57.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,,8.74,,,percent of total billed charges,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.33,,,percent of total billed charges,,
EPOETIN ALFA EPBX 3000U ESRD,2500032748,CDM,634,RC,Q5105,HCPCS,69130610,NDC,,,,outpatient,facility,1,UN,109.19,109.19,0.7,548.68,,77.43,,,percent of total billed charges,,,,,,,,,109.19,,,percent of total billed charges,,,0.88,,,fee schedule,,,0.84,,,fee schedule,,,,,,,,,0.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,109.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,109.19,,,fee schedule,,,109.19,,,percent of total billed charges,,,,,,,,,109.19,,,percent of total billed charges,,,66.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.8,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,fee schedule,,,0.78,,,fee schedule,,,0.78,,,fee schedule,,,,,,,,,64.42,,,percent of total billed charges,,,548.68,,,per diem,,,109.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,109.19,,,percent of total billed charges,,,92.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.99,,,percent of total billed charges,,,109.19,,,percent of total billed charges,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.66,,,percent of total billed charges,,,88.36,,,percent of total billed charges,,,,,,,,,,,,,,,43.68,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,,8.74,,,percent of total billed charges,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,,109.19,,,percent of total billed charges,,,109.19,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.7,,,fee schedule,,,109.19,,,percent of total billed charges,,,109.19,,,percent of total billed charges,,,109.19,,,percent of total billed charges,,,,,,,,,76.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.59,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,64.33,,,percent of total billed charges,,
EPOETIN ALFA EPBX 3000U ESRD,2500032748,CDM,634,RC,Q5105,HCPCS,69130610,NDC,9096,APC,,outpatient,facility,1,UN,109.19,109.19,0.72,39.96,,,,,,,,0.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,fee schedule,,,,,,,,,39.96,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.79,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,,,,,,,1.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,fee schedule,,,0.8,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,0.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,0.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.78,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,
EPOETIN ALFA EPBX 3000U ESRD,2500032748,CDM,634,RC,Q5105,HCPCS,69130610,NDC,436,EAPG,,outpatient,facility,1,UN,109.19,109.19,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA EPBX 4000U ESRD,2500032749,CDM,634,RC,Q5105,HCPCS,69130710,NDC,,,,inpatient,facility,1,UN,145.59,145.59,11.65,145.59,,,,,,,,,,,,,,145.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.59,,,percent of total billed charges,,,,,,,,,145.59,,,percent of total billed charges,,,74.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.35,,,percent of total billed charges,,,,,,,,,,,,,,,145.59,,,percent of total billed charges,,,123.75,,,percent of total billed charges,,,,,,,,,,,,,,,145.59,,,percent of total billed charges,,,77.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,145.59,,,percent of total billed charges,,,,,,,,,,,,,,,11.65,,,percent of total billed charges,,,145.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,145.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.78,,,percent of total billed charges,,
EPOETIN ALFA EPBX 4000U ESRD,2500032749,CDM,634,RC,Q5105,HCPCS,69130710,NDC,,,,outpatient,facility,1,UN,145.59,145.59,0.7,548.68,,103.24,,,percent of total billed charges,,,,,,,,,145.59,,,percent of total billed charges,,,0.88,,,fee schedule,,,0.84,,,fee schedule,,,,,,,,,0.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,145.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,145.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,145.59,,,fee schedule,,,145.59,,,percent of total billed charges,,,,,,,,,145.59,,,percent of total billed charges,,,89.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.73,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,fee schedule,,,0.78,,,fee schedule,,,0.78,,,fee schedule,,,,,,,,,85.9,,,percent of total billed charges,,,548.68,,,per diem,,,145.59,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,145.59,,,percent of total billed charges,,,123.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.32,,,percent of total billed charges,,,145.59,,,percent of total billed charges,,,145.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.22,,,percent of total billed charges,,,117.81,,,percent of total billed charges,,,,,,,,,,,,,,,58.24,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,145.59,,,percent of total billed charges,,,,,,,,,,,,,,,11.65,,,percent of total billed charges,,,145.59,,,percent of total billed charges,,,,,,,,,,,,,,,145.59,,,percent of total billed charges,,,145.59,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.7,,,fee schedule,,,145.59,,,percent of total billed charges,,,145.59,,,percent of total billed charges,,,145.59,,,percent of total billed charges,,,,,,,,,102.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.8,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,85.78,,,percent of total billed charges,,
EPOETIN ALFA EPBX 4000U ESRD,2500032749,CDM,634,RC,Q5105,HCPCS,69130710,NDC,9096,APC,,outpatient,facility,1,UN,145.59,145.59,0.72,53.29,,,,,,,,0.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,fee schedule,,,,,,,,,53.29,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.79,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,,,,,,,1.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,fee schedule,,,0.8,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,0.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,0.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.78,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,
EPOETIN ALFA EPBX 4000U ESRD,2500032749,CDM,634,RC,Q5105,HCPCS,69130710,NDC,436,EAPG,,outpatient,facility,1,UN,145.59,145.59,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA EPBX 10000U ESRD,2500032750,CDM,635,RC,Q5105,HCPCS,69130810,NDC,,,,inpatient,facility,1,UN,363.99,363.99,29.12,363.99,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,363.99,,,percent of total billed charges,,,185.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,310.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.39,,,percent of total billed charges,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,309.39,,,percent of total billed charges,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,193.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,29.12,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.46,,,percent of total billed charges,,
EPOETIN ALFA EPBX 10000U ESRD,2500032750,CDM,635,RC,Q5105,HCPCS,69130810,NDC,,,,outpatient,facility,1,UN,363.99,363.99,0.7,548.68,,258.11,,,percent of total billed charges,,,,,,,,,363.99,,,percent of total billed charges,,,0.88,,,fee schedule,,,0.84,,,fee schedule,,,,,,,,,0.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,363.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,363.99,,,fee schedule,,,363.99,,,percent of total billed charges,,,,,,,,,363.99,,,percent of total billed charges,,,223.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,259.34,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,fee schedule,,,0.78,,,fee schedule,,,0.78,,,fee schedule,,,,,,,,,214.75,,,percent of total billed charges,,,548.68,,,per diem,,,363.99,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,363.99,,,percent of total billed charges,,,309.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,193.32,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.55,,,percent of total billed charges,,,294.54,,,percent of total billed charges,,,,,,,,,,,,,,,145.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,29.12,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.7,,,fee schedule,,,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,363.99,,,percent of total billed charges,,,,,,,,,255.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,214.46,,,percent of total billed charges,,
EPOETIN ALFA EPBX 10000U ESRD,2500032750,CDM,635,RC,Q5105,HCPCS,69130810,NDC,9096,APC,,outpatient,facility,1,UN,363.99,363.99,0.72,133.22,,,,,,,,0.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,fee schedule,,,,,,,,,133.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.79,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,,,,,,,1.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,fee schedule,,,0.8,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,0.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,0.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.78,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,
EPOETIN ALFA EPBX 10000U ESRD,2500032750,CDM,635,RC,Q5105,HCPCS,69130810,NDC,436,EAPG,,outpatient,facility,1,UN,363.99,363.99,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
EPOETIN ALFA EPBX 40000U ESRD,2500032751,CDM,635,RC,Q5105,HCPCS,69130904,NDC,,,,inpatient,facility,1,UN,1455.96,1455.96,116.48,1455.96,,,,,,,,,,,,,,1455.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1455.96,,,percent of total billed charges,,,,,,,,,1455.96,,,percent of total billed charges,,,743.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1240.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.58,,,percent of total billed charges,,,,,,,,,,,,,,,1455.96,,,percent of total billed charges,,,1237.57,,,percent of total billed charges,,,,,,,,,,,,,,,1455.96,,,percent of total billed charges,,,773.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,582.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,1455.96,,,percent of total billed charges,,,,,,,,,,,,,,,116.48,,,percent of total billed charges,,,1455.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1455.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,857.85,,,percent of total billed charges,,
EPOETIN ALFA EPBX 40000U ESRD,2500032751,CDM,635,RC,Q5105,HCPCS,69130904,NDC,,,,outpatient,facility,1,UN,1455.96,1455.96,0.7,1455.96,,1032.42,,,percent of total billed charges,,,,,,,,,1455.96,,,percent of total billed charges,,,0.88,,,fee schedule,,,0.84,,,fee schedule,,,,,,,,,0.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1455.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,1455.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,1455.96,,,fee schedule,,,1455.96,,,percent of total billed charges,,,,,,,,,1455.96,,,percent of total billed charges,,,892.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1037.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.78,,,fee schedule,,,0.78,,,fee schedule,,,0.78,,,fee schedule,,,,,,,,,859.02,,,percent of total billed charges,,,548.68,,,per diem,,,1455.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,1455.96,,,percent of total billed charges,,,1237.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,773.26,,,percent of total billed charges,,,1455.96,,,percent of total billed charges,,,1455.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,982.19,,,percent of total billed charges,,,1178.16,,,percent of total billed charges,,,,,,,,,,,,,,,582.38,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,,1455.96,,,percent of total billed charges,,,,,,,,,,,,,,,116.48,,,percent of total billed charges,,,1455.96,,,percent of total billed charges,,,,,,,,,,,,,,,1455.96,,,percent of total billed charges,,,1455.96,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,0.7,,,fee schedule,,,1455.96,,,percent of total billed charges,,,1455.96,,,percent of total billed charges,,,1455.96,,,percent of total billed charges,,,,,,,,,1020.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,727.98,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,857.85,,,percent of total billed charges,,
EPOETIN ALFA EPBX 40000U ESRD,2500032751,CDM,635,RC,Q5105,HCPCS,69130904,NDC,9096,APC,,outpatient,facility,1,UN,1455.96,1455.96,0.72,532.88,,,,,,,,0.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.76,,,fee schedule,,,,,,,,,532.88,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.79,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,,,,,,,1.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.72,,,fee schedule,,,0.8,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,,,,,,,,,,,,,0.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,0.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,0.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,0.75,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,0.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,fee schedule,,,,,,,,,,,,,,,0.78,,,fee schedule,,,0.75,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,,,,,,,0.75,,,fee schedule,,,0.79,,,fee schedule,,,,,,,,
EPOETIN ALFA EPBX 40000U ESRD,2500032751,CDM,635,RC,Q5105,HCPCS,69130904,NDC,436,EAPG,,outpatient,facility,1,UN,1455.96,1455.96,130.78,197.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.48,,,fee schedule,,,130.78,,,fee schedule,,,175.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,130.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GUANFACINE 1 MG ER TAB,2500032753,CDM,637,RC,6050539271,NDC,,,,,,inpatient,facility,1,UN,34.61,34.61,2.77,34.61,,,,,,,,,,,,,,34.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.61,,,percent of total billed charges,,,,,,,,,34.61,,,percent of total billed charges,,,17.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,34.61,,,percent of total billed charges,,,29.42,,,percent of total billed charges,,,,,,,,,,,,,,,34.61,,,percent of total billed charges,,,18.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,34.61,,,percent of total billed charges,,,,,,,,,,,,,,,2.77,,,percent of total billed charges,,,34.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.39,,,percent of total billed charges,,
GUANFACINE 1 MG ER TAB,2500032753,CDM,637,RC,6050539271,NDC,,,,,,outpatient,facility,1,UN,34.61,34.61,2.77,548.68,,24.54,,,percent of total billed charges,,,8.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,34.61,,,percent of total billed charges,,,21.69,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,24.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,24.33,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,34.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,12.67,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,34.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,34.61,,,fee schedule,,,34.61,,,percent of total billed charges,,,,,,,,,34.61,,,percent of total billed charges,,,21.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.66,,,percent of total billed charges,,,,,,,,,,,,,,,18.69,,,percent of total billed charges,,,18,,,percent of total billed charges,,,19.04,,,percent of total billed charges,,,,,,,,,20.42,,,percent of total billed charges,,,548.68,,,per diem,,,34.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,34.61,,,percent of total billed charges,,,29.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.38,,,percent of total billed charges,,,34.61,,,percent of total billed charges,,,34.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.35,,,percent of total billed charges,,,28.01,,,percent of total billed charges,,,,,,,,,,,,,,,13.84,,,percent of total billed charges,,,,,,,,,12.81,,,percent of total billed charges,,,12.81,,,percent of total billed charges,,,,,,,,,34.61,,,percent of total billed charges,,,34.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,34.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.77,,,percent of total billed charges,,,34.61,,,percent of total billed charges,,,,,,,,,,,,,,,34.61,,,percent of total billed charges,,,34.61,,,percent of total billed charges,,,,,,,,,32.19,,,percent of total billed charges,,,,,,,,,,,,,,,32.19,,,percent of total billed charges,,,32.19,,,percent of total billed charges,,,32.19,,,percent of total billed charges,,,25.96,,,percent of total billed charges,,,34.61,,,percent of total billed charges,,,34.61,,,percent of total billed charges,,,34.61,,,percent of total billed charges,,,,,,,,,24.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.3,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,20.39,,,percent of total billed charges,,
GUANFACINE 1 MG ER TAB,2500032753,CDM,637,RC,6050539271,NDC,999,EAPG,,,,outpatient,facility,1,UN,34.61,34.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
AMMONIUM LACTATE 12 -140GM CRM,2500032754,CDM,637,RC,904598348,NDC,,,,,,inpatient,facility,140,UN,74.05,74.05,5.92,74.05,,,,,,,,,,,,,,74.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.05,,,percent of total billed charges,,,,,,,,,74.05,,,percent of total billed charges,,,37.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.43,,,percent of total billed charges,,,,,,,,,,,,,,,74.05,,,percent of total billed charges,,,62.94,,,percent of total billed charges,,,,,,,,,,,,,,,74.05,,,percent of total billed charges,,,39.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,74.05,,,percent of total billed charges,,,,,,,,,,,,,,,5.92,,,percent of total billed charges,,,74.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.63,,,percent of total billed charges,,
AMMONIUM LACTATE 12 -140GM CRM,2500032754,CDM,637,RC,904598348,NDC,,,,,,outpatient,facility,140,UN,74.05,74.05,5.92,548.68,,52.51,,,percent of total billed charges,,,18.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,74.05,,,percent of total billed charges,,,46.41,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,52.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,52.06,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,74.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,27.1,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,74.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,74.05,,,fee schedule,,,74.05,,,percent of total billed charges,,,,,,,,,74.05,,,percent of total billed charges,,,45.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.76,,,percent of total billed charges,,,,,,,,,,,,,,,39.99,,,percent of total billed charges,,,38.51,,,percent of total billed charges,,,40.73,,,percent of total billed charges,,,,,,,,,43.69,,,percent of total billed charges,,,548.68,,,per diem,,,74.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,74.05,,,percent of total billed charges,,,62.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.33,,,percent of total billed charges,,,74.05,,,percent of total billed charges,,,74.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.95,,,percent of total billed charges,,,59.92,,,percent of total billed charges,,,,,,,,,,,,,,,29.62,,,percent of total billed charges,,,,,,,,,27.4,,,percent of total billed charges,,,27.4,,,percent of total billed charges,,,,,,,,,74.05,,,percent of total billed charges,,,74.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,74.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,5.92,,,percent of total billed charges,,,74.05,,,percent of total billed charges,,,,,,,,,,,,,,,74.05,,,percent of total billed charges,,,74.05,,,percent of total billed charges,,,,,,,,,68.88,,,percent of total billed charges,,,,,,,,,,,,,,,68.88,,,percent of total billed charges,,,68.88,,,percent of total billed charges,,,68.88,,,percent of total billed charges,,,55.54,,,percent of total billed charges,,,74.05,,,percent of total billed charges,,,74.05,,,percent of total billed charges,,,74.05,,,percent of total billed charges,,,,,,,,,51.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.02,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,43.63,,,percent of total billed charges,,
AMMONIUM LACTATE 12 -140GM CRM,2500032754,CDM,637,RC,904598348,NDC,999,EAPG,,,,outpatient,facility,140,UN,74.05,74.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
GLYCOPYRR/FORMOTEROL 5.9GM INH,2500032757,CDM,250,RC,310460039,NDC,,,,,,inpatient,facility,5.9,UN,718.97,718.97,57.52,718.97,,,,,,,,,,,,,,718.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,718.97,,,percent of total billed charges,,,,,,,,,718.97,,,percent of total billed charges,,,367.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,431.38,,,percent of total billed charges,,,,,,,,,,,,,,,718.97,,,percent of total billed charges,,,611.12,,,percent of total billed charges,,,,,,,,,,,,,,,718.97,,,percent of total billed charges,,,381.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,718.97,,,percent of total billed charges,,,,,,,,,,,,,,,57.52,,,percent of total billed charges,,,718.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,718.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,423.62,,,percent of total billed charges,,
GLYCOPYRR/FORMOTEROL 5.9GM INH,2500032757,CDM,250,RC,310460039,NDC,,,,,,outpatient,facility,5.9,UN,718.97,718.97,57.52,718.97,,509.82,,,percent of total billed charges,,,175.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,718.97,,,percent of total billed charges,,,450.58,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,505.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,505.44,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,718.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,263.14,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,718.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,718.97,,,fee schedule,,,718.97,,,percent of total billed charges,,,,,,,,,718.97,,,percent of total billed charges,,,440.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,service not payable,,,,,,service not payable,,,,,,,424.19,,,percent of total billed charges,,,548.68,,,per diem,,,718.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,718.97,,,percent of total billed charges,,,611.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,381.84,,,percent of total billed charges,,,718.97,,,percent of total billed charges,,,718.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,485.02,,,percent of total billed charges,,,581.79,,,percent of total billed charges,,,,,,,,,,,,,,,287.59,,,percent of total billed charges,,,,,,,,,287.59,,,percent of total billed charges,,,287.59,,,percent of total billed charges,,,,,,,,,718.97,,,percent of total billed charges,,,718.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,718.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,57.52,,,percent of total billed charges,,,718.97,,,percent of total billed charges,,,,,,,,,,,,,,,718.97,,,percent of total billed charges,,,718.97,,,percent of total billed charges,,,,,,,,,287.59,,,percent of total billed charges,,,,,,,,,,,,,,,287.59,,,percent of total billed charges,,,287.59,,,percent of total billed charges,,,287.59,,,percent of total billed charges,,,539.23,,,percent of total billed charges,,,718.97,,,percent of total billed charges,,,718.97,,,percent of total billed charges,,,718.97,,,percent of total billed charges,,,,,,,,,504.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.49,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,423.62,,,percent of total billed charges,,
GLYCOPYRR/FORMOTEROL 5.9GM INH,2500032757,CDM,250,RC,310460039,NDC,999,EAPG,,,,outpatient,facility,5.9,UN,718.97,718.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IODINE/POTASSIUM IODIDE 14ML,2500032762,CDM,637,RC,4843323015,NDC,,,,,,inpatient,facility,14,UN,106.43,106.43,8.51,106.43,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,,,,,106.43,,,percent of total billed charges,,,54.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.86,,,percent of total billed charges,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,90.47,,,percent of total billed charges,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,56.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,,,,,,,,,,,8.51,,,percent of total billed charges,,,106.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.71,,,percent of total billed charges,,
IODINE/POTASSIUM IODIDE 14ML,2500032762,CDM,637,RC,4843323015,NDC,,,,,,outpatient,facility,14,UN,106.43,106.43,8.51,548.68,,75.47,,,percent of total billed charges,,,25.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,106.43,,,percent of total billed charges,,,66.7,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,74.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,74.82,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,38.95,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,106.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,106.43,,,fee schedule,,,106.43,,,percent of total billed charges,,,,,,,,,106.43,,,percent of total billed charges,,,65.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.83,,,percent of total billed charges,,,,,,,,,,,,,,,57.47,,,percent of total billed charges,,,55.34,,,percent of total billed charges,,,58.54,,,percent of total billed charges,,,,,,,,,62.79,,,percent of total billed charges,,,548.68,,,per diem,,,106.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,106.43,,,percent of total billed charges,,,90.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.52,,,percent of total billed charges,,,106.43,,,percent of total billed charges,,,106.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.8,,,percent of total billed charges,,,86.12,,,percent of total billed charges,,,,,,,,,,,,,,,42.57,,,percent of total billed charges,,,,,,,,,39.38,,,percent of total billed charges,,,39.38,,,percent of total billed charges,,,,,,,,,106.43,,,percent of total billed charges,,,106.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,106.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,8.51,,,percent of total billed charges,,,106.43,,,percent of total billed charges,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,106.43,,,percent of total billed charges,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,99,,,percent of total billed charges,,,79.82,,,percent of total billed charges,,,106.43,,,percent of total billed charges,,,106.43,,,percent of total billed charges,,,106.43,,,percent of total billed charges,,,,,,,,,74.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.22,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,62.71,,,percent of total billed charges,,
IODINE/POTASSIUM IODIDE 14ML,2500032762,CDM,637,RC,4843323015,NDC,999,EAPG,,,,outpatient,facility,14,UN,106.43,106.43,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIVAROXABAN 2.5 MG TAB,2500032773,CDM,637,RC,5045857710,NDC,,,,,,inpatient,facility,2.5,UN,31.32,31.32,2.51,31.32,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,,,,,,,31.32,,,percent of total billed charges,,,15.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.79,,,percent of total billed charges,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,26.62,,,percent of total billed charges,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,16.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,,,,,,,,,,,,,2.51,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.45,,,percent of total billed charges,,
RIVAROXABAN 2.5 MG TAB,2500032773,CDM,637,RC,5045857710,NDC,,,,,,outpatient,facility,2.5,UN,31.32,31.32,2.51,548.68,,22.21,,,percent of total billed charges,,,7.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,31.32,,,percent of total billed charges,,,19.63,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,22.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,22.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,11.46,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,31.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,31.32,,,fee schedule,,,31.32,,,percent of total billed charges,,,,,,,,,31.32,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.32,,,percent of total billed charges,,,,,,,,,,,,,,,16.91,,,percent of total billed charges,,,16.29,,,percent of total billed charges,,,17.23,,,percent of total billed charges,,,,,,,,,18.48,,,percent of total billed charges,,,548.68,,,per diem,,,31.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,31.32,,,percent of total billed charges,,,26.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.63,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.13,,,percent of total billed charges,,,25.34,,,percent of total billed charges,,,,,,,,,,,,,,,12.53,,,percent of total billed charges,,,,,,,,,11.59,,,percent of total billed charges,,,11.59,,,percent of total billed charges,,,,,,,,,31.32,,,percent of total billed charges,,,31.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,31.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.51,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,,,,,,,29.13,,,percent of total billed charges,,,,,,,,,,,,,,,29.13,,,percent of total billed charges,,,29.13,,,percent of total billed charges,,,29.13,,,percent of total billed charges,,,23.49,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,,,,,,,21.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.66,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,18.45,,,percent of total billed charges,,
RIVAROXABAN 2.5 MG TAB,2500032773,CDM,637,RC,5045857710,NDC,999,EAPG,,,,outpatient,facility,2.5,UN,31.32,31.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
NALDEMEDINE 0.2 MG TAB,2500032786,CDM,637,RC,5938504130,NDC,,,,,,inpatient,facility,0.2,UN,61.08,61.08,4.89,61.08,,,,,,,,,,,,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.08,,,percent of total billed charges,,,,,,,,,61.08,,,percent of total billed charges,,,31.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.65,,,percent of total billed charges,,,,,,,,,,,,,,,61.08,,,percent of total billed charges,,,51.92,,,percent of total billed charges,,,,,,,,,,,,,,,61.08,,,percent of total billed charges,,,32.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,4.89,,,percent of total billed charges,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.99,,,percent of total billed charges,,
NALDEMEDINE 0.2 MG TAB,2500032786,CDM,637,RC,5938504130,NDC,,,,,,outpatient,facility,0.2,UN,61.08,61.08,4.89,548.68,,43.31,,,percent of total billed charges,,,14.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,61.08,,,percent of total billed charges,,,38.28,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,42.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,42.94,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,22.36,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,61.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,61.08,,,fee schedule,,,61.08,,,percent of total billed charges,,,,,,,,,61.08,,,percent of total billed charges,,,37.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.52,,,percent of total billed charges,,,,,,,,,,,,,,,32.98,,,percent of total billed charges,,,31.76,,,percent of total billed charges,,,33.59,,,percent of total billed charges,,,,,,,,,36.04,,,percent of total billed charges,,,548.68,,,per diem,,,61.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,61.08,,,percent of total billed charges,,,51.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.44,,,percent of total billed charges,,,61.08,,,percent of total billed charges,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.2,,,percent of total billed charges,,,49.43,,,percent of total billed charges,,,,,,,,,,,,,,,24.43,,,percent of total billed charges,,,,,,,,,22.6,,,percent of total billed charges,,,22.6,,,percent of total billed charges,,,,,,,,,61.08,,,percent of total billed charges,,,61.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,61.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,4.89,,,percent of total billed charges,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,61.08,,,percent of total billed charges,,,61.08,,,percent of total billed charges,,,,,,,,,56.82,,,percent of total billed charges,,,,,,,,,,,,,,,56.82,,,percent of total billed charges,,,56.82,,,percent of total billed charges,,,56.82,,,percent of total billed charges,,,45.81,,,percent of total billed charges,,,61.08,,,percent of total billed charges,,,61.08,,,percent of total billed charges,,,61.08,,,percent of total billed charges,,,,,,,,,42.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.54,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,35.99,,,percent of total billed charges,,
NALDEMEDINE 0.2 MG TAB,2500032786,CDM,637,RC,5938504130,NDC,999,EAPG,,,,outpatient,facility,0.2,UN,61.08,61.08,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CEMIPLIMAB-RWLC 350 MG VIAL,2500032788,CDM,636,RC,J9119,HCPCS,6175500801,NDC,,,,inpatient,facility,7,ML,33982.81,33982.81,2718.62,33982.81,,,,,,,,,,,,,,33982.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33982.81,,,percent of total billed charges,,,,,,,,,33982.81,,,percent of total billed charges,,,17351.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28943.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20389.69,,,percent of total billed charges,,,,,,,,,,,,,,,33982.81,,,percent of total billed charges,,,28885.39,,,percent of total billed charges,,,,,,,,,,,,,,,33982.81,,,percent of total billed charges,,,18048.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13593.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,33982.81,,,percent of total billed charges,,,,,,,,,,,,,,,2718.62,,,percent of total billed charges,,,33982.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33982.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20022.67,,,percent of total billed charges,,
CEMIPLIMAB-RWLC 350 MG VIAL,2500032788,CDM,636,RC,J9119,HCPCS,6175500801,NDC,,,,outpatient,facility,7,ML,33982.81,33982.81,18.6,33982.81,,27.58,,,fee schedule,,,,,,,,,33982.81,,,percent of total billed charges,,,35.95,,,fee schedule,,,34.02,,,fee schedule,,,,,,,,,34.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,33982.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,33982.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,33982.81,,,fee schedule,,,33982.81,,,percent of total billed charges,,,,,,,,,33982.81,,,percent of total billed charges,,,20828.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24212.75,,,percent of total billed charges,,,,,,,,,,,,,,,27.46,,,fee schedule,,,27.46,,,fee schedule,,,27.46,,,fee schedule,,,,,,,,,20049.86,,,percent of total billed charges,,,548.68,,,per diem,,,33982.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,33982.81,,,percent of total billed charges,,,28885.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18048.27,,,percent of total billed charges,,,33982.81,,,percent of total billed charges,,,33982.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22924.8,,,percent of total billed charges,,,27498.89,,,percent of total billed charges,,,,,,,,,,,,,,,13593.12,,,percent of total billed charges,,,,,,,,,66.98,,,fee schedule,,,48.2,,,fee schedule,,,,,,,,,33982.81,,,percent of total billed charges,,,,,,,,,,,,,,,2718.62,,,percent of total billed charges,,,33982.81,,,percent of total billed charges,,,,,,,,,,,,,,,33982.81,,,percent of total billed charges,,,33982.81,,,percent of total billed charges,,,,,,,,,28.62,,,fee schedule,,,,,,,,,,,,,,,24.81,,,fee schedule,,,33.08,,,fee schedule,,,18.6,,,fee schedule,,,28.74,,,fee schedule,,,33982.81,,,percent of total billed charges,,,33982.81,,,percent of total billed charges,,,33982.81,,,percent of total billed charges,,,,,,,,,23825.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16991.4,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,20022.67,,,percent of total billed charges,,
CEMIPLIMAB-RWLC 350 MG VIAL,2500032788,CDM,636,RC,J9119,HCPCS,6175500801,NDC,9304,APC,,outpatient,facility,7,ML,33982.81,33982.81,27.08,12437.71,,,,,,,,29.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,28.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.49,,,fee schedule,,,,,,,,,12437.71,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,28.21,,,fee schedule,,,,,,,,,,,,,,,29.62,,,fee schedule,,,29.62,,,fee schedule,,,,,,,,,28.21,,,fee schedule,,,28.21,,,fee schedule,,,29.62,,,fee schedule,,,,,,,,,,,,,,,42.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,28.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.08,,,fee schedule,,,30.18,,,fee schedule,,,29.62,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.21,,,fee schedule,,,28.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,29.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,28.21,,,fee schedule,,,,,,,,,35.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,35.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,28.21,,,fee schedule,,,28.21,,,fee schedule,,,,,,,,,,,,,,,28.21,,,fee schedule,,,,,,,,,28.21,,,fee schedule,,,29.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.21,,,fee schedule,,,,,,,,,,,,,,,29.34,,,fee schedule,,,28.21,,,fee schedule,,,,,,,,,28.21,,,fee schedule,,,,,,,,,28.21,,,fee schedule,,,29.62,,,fee schedule,,,,,,,,
CEMIPLIMAB-RWLC 350 MG VIAL,2500032788,CDM,636,RC,J9119,HCPCS,6175500801,NDC,463,EAPG,,outpatient,facility,7,ML,33982.81,33982.81,7053.67,10651.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10651.04,,,fee schedule,,,7053.67,,,fee schedule,,,9468.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,7053.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
IMMUNE GLOB IV 40 GM/ GAMUNEX,2500032792,CDM,636,RC,J1561,HCPCS,1353380040,NDC,,,,inpatient,facility,400,ML,18435.12,18435.12,1474.81,18435.12,,,,,,,,,,,,,,18435.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18435.12,,,percent of total billed charges,,,,,,,,,18435.12,,,percent of total billed charges,,,9412.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15701.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11061.07,,,percent of total billed charges,,,,,,,,,,,,,,,18435.12,,,percent of total billed charges,,,15669.85,,,percent of total billed charges,,,,,,,,,,,,,,,18435.12,,,percent of total billed charges,,,9790.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7374.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,18435.12,,,percent of total billed charges,,,,,,,,,,,,,,,1474.81,,,percent of total billed charges,,,18435.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18435.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10861.97,,,percent of total billed charges,,
IMMUNE GLOB IV 40 GM/ GAMUNEX,2500032792,CDM,636,RC,J1561,HCPCS,1353380040,NDC,,,,outpatient,facility,400,ML,18435.12,18435.12,30.49,18435.12,,13072.34,,,percent of total billed charges,,,,,,,,,18435.12,,,percent of total billed charges,,,64.35,,,fee schedule,,,60.88,,,fee schedule,,,,,,,,,60.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,18435.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,service not payable,42.96,,,fee schedule,,,18435.12,,,fee schedule,,,18435.12,,,percent of total billed charges,,,,,,,,,18435.12,,,percent of total billed charges,,,11298.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13135.02,,,percent of total billed charges,,,,,,,,,,,,,,,49.79,,,fee schedule,,,49.79,,,fee schedule,,,49.79,,,fee schedule,,,,,,,,,10876.72,,,percent of total billed charges,,,548.68,,,per diem,,,18435.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,18435.12,,,percent of total billed charges,,,15669.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9790.89,,,percent of total billed charges,,,18435.12,,,percent of total billed charges,,,18435.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12436.33,,,percent of total billed charges,,,14917.7,,,percent of total billed charges,,,,,,,,,,,,,,,7374.05,,,percent of total billed charges,,,,,,,,,109.75,,,fee schedule,,,78.98,,,fee schedule,,,,,,,,,18435.12,,,percent of total billed charges,,,,,,,,,,,,,,,1474.81,,,percent of total billed charges,,,18435.12,,,percent of total billed charges,,,,,,,,,,,,,,,18435.12,,,percent of total billed charges,,,18435.12,,,percent of total billed charges,,,,,,,,,46.9,,,fee schedule,,,,,,,,,,,,,,,40.65,,,fee schedule,,,54.2,,,fee schedule,,,30.49,,,fee schedule,,,51.45,,,fee schedule,,,18435.12,,,percent of total billed charges,,,18435.12,,,percent of total billed charges,,,18435.12,,,percent of total billed charges,,,,,,,,,12924.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9217.56,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,10861.97,,,percent of total billed charges,,
IMMUNE GLOB IV 40 GM/ GAMUNEX,2500032792,CDM,636,RC,J1561,HCPCS,1353380040,NDC,948,APC,,outpatient,facility,400,ML,18435.12,18435.12,47.05,6747.25,,,,,,,,50.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.5,,,fee schedule,,,,,,,,,6747.25,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,51.46,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,49.01,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,,,,,,,,73.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.05,,,fee schedule,,,52.44,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,49.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,50.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,61.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,61.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,49.01,,,fee schedule,,,49.01,,,fee schedule,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,50.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.01,,,fee schedule,,,,,,,,,,,,,,,50.97,,,fee schedule,,,49.01,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,,,,,,,49.01,,,fee schedule,,,51.46,,,fee schedule,,,,,,,,
IMMUNE GLOB IV 40 GM/ GAMUNEX,2500032792,CDM,636,RC,J1561,HCPCS,1353380040,NDC,460,EAPG,,outpatient,facility,400,ML,18435.12,18435.12,1604.23,2422.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2422.39,,,fee schedule,,,1604.23,,,fee schedule,,,2153.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
CANGRELOR 50 MG INJ,2500032798,CDM,636,RC,C9460,HCPCS,1012262010,NDC,,,,inpatient,facility,50,UN,3779.56,3779.56,302.36,3779.56,,,,,,,,,,,,,,3779.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3779.56,,,percent of total billed charges,,,,,,,,,3779.56,,,percent of total billed charges,,,1929.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3219.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2267.74,,,percent of total billed charges,,,,,,,,,,,,,,,3779.56,,,percent of total billed charges,,,3212.63,,,percent of total billed charges,,,,,,,,,,,,,,,3779.56,,,percent of total billed charges,,,2007.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1511.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,3779.56,,,percent of total billed charges,,,,,,,,,,,,,,,302.36,,,percent of total billed charges,,,3779.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3779.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2226.92,,,percent of total billed charges,,
CANGRELOR 50 MG INJ,2500032798,CDM,636,RC,C9460,HCPCS,1012262010,NDC,,,,outpatient,facility,50,UN,3779.56,3779.56,11.69,3779.56,,2680.09,,,percent of total billed charges,,,,,,,,,3779.56,,,percent of total billed charges,,,28.24,,,fee schedule,,,26.72,,,fee schedule,,,,,,,,,26.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,3779.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,3779.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,3779.56,,,fee schedule,,,3779.56,,,percent of total billed charges,,,,,,,,,3779.56,,,percent of total billed charges,,,2316.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2692.94,,,percent of total billed charges,,,,,,,,,,,,,,,18.2,,,fee schedule,,,18.2,,,fee schedule,,,18.2,,,fee schedule,,,,,,,,,2229.94,,,percent of total billed charges,,,548.68,,,per diem,,,3779.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,3779.56,,,percent of total billed charges,,,3212.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2007.32,,,percent of total billed charges,,,3779.56,,,percent of total billed charges,,,3779.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2549.69,,,percent of total billed charges,,,3058.42,,,percent of total billed charges,,,,,,,,,,,,,,,1511.82,,,percent of total billed charges,,,,,,,,,42.09,,,fee schedule,,,30.29,,,fee schedule,,,,,,,,,3779.56,,,percent of total billed charges,,,,,,,,,,,,,,,302.36,,,percent of total billed charges,,,3779.56,,,percent of total billed charges,,,,,,,,,,,,,,,3779.56,,,percent of total billed charges,,,3779.56,,,percent of total billed charges,,,,,,,,,17.99,,,fee schedule,,,,,,,,,,,,,,,15.59,,,fee schedule,,,20.79,,,fee schedule,,,11.69,,,fee schedule,,,2834.67,,,percent of total billed charges,,,3779.56,,,percent of total billed charges,,,3779.56,,,percent of total billed charges,,,3779.56,,,percent of total billed charges,,,,,,,,,2649.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1889.78,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,2226.92,,,percent of total billed charges,,
CANGRELOR 50 MG INJ,2500032798,CDM,636,RC,C9460,HCPCS,1012262010,NDC,9460,APC,,outpatient,facility,50,UN,3779.56,3779.56,18.07,1383.32,,,,,,,,19.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,18.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.01,,,fee schedule,,,,,,,,,1383.32,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,18.82,,,fee schedule,,,,,,,,,,,,,,,19.76,,,fee schedule,,,19.76,,,fee schedule,,,,,,,,,18.82,,,fee schedule,,,18.82,,,fee schedule,,,19.76,,,fee schedule,,,,,,,,,,,,,,,28.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,18.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.07,,,fee schedule,,,20.14,,,fee schedule,,,19.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.82,,,fee schedule,,,18.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,19.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,18.82,,,fee schedule,,,,,,,,,23.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,23.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,18.82,,,fee schedule,,,18.82,,,fee schedule,,,,,,,,,,,,,,,18.82,,,fee schedule,,,,,,,,,18.82,,,fee schedule,,,19.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.82,,,fee schedule,,,,,,,,,,,,,,,19.57,,,fee schedule,,,18.82,,,fee schedule,,,,,,,,,18.82,,,fee schedule,,,,,,,,,18.82,,,fee schedule,,,19.76,,,fee schedule,,,,,,,,
CANGRELOR 50 MG INJ,2500032798,CDM,636,RC,C9460,HCPCS,1012262010,NDC,999,EAPG,,outpatient,facility,50,UN,3779.56,3779.56,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
OCRELIZUMAB 300MG/10ML INJ,2500032805,CDM,636,RC,J2350,HCPCS,5024215001,NDC,,,,inpatient,facility,10,ML,0.01,0.01,0.01,0.01,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
OCRELIZUMAB 300MG/10ML INJ,2500032805,CDM,636,RC,J2350,HCPCS,5024215001,NDC,,,,outpatient,facility,10,ML,0.01,0.01,0.01,548.68,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,78.2,,,fee schedule,,,73.99,,,fee schedule,,,,,,,,,73.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,548.68,,,per diem,,,0.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,service not payable,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,fee schedule,,,,,,,,,,,,,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,fee schedule,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,0.01,,,percent of total billed charges,,,,,,,,,0.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.01,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,0.01,,,percent of total billed charges,,
OCRELIZUMAB 300MG/10ML INJ,2500032805,CDM,636,RC,J2350,HCPCS,5024215001,NDC,9494,APC,,outpatient,facility,10,ML,0.01,0.01,56.42,88.16,,,,,,,,60.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,58.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.77,,,fee schedule,,,,,,,,,,,,,,,61.71,,,fee schedule,,,61.71,,,fee schedule,,,,,,,,,58.77,,,fee schedule,,,58.77,,,fee schedule,,,61.71,,,fee schedule,,,,,,,,,,,,,,,88.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,58.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.42,,,fee schedule,,,62.88,,,fee schedule,,,61.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.77,,,fee schedule,,,58.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,61.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,58.77,,,fee schedule,,,,,,,,,73.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,73.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,58.77,,,fee schedule,,,58.77,,,fee schedule,,,,,,,,,,,,,,,58.77,,,fee schedule,,,,,,,,,58.77,,,fee schedule,,,60.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.77,,,fee schedule,,,,,,,,,,,,,,,61.12,,,fee schedule,,,58.77,,,fee schedule,,,,,,,,,58.77,,,fee schedule,,,,,,,,,58.77,,,fee schedule,,,61.71,,,fee schedule,,,,,,,,
OCRELIZUMAB 300MG/10ML INJ,2500032805,CDM,636,RC,J2350,HCPCS,5024215001,NDC,466,EAPG,,outpatient,facility,10,ML,0.01,0.01,58.77,88.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.74,,,fee schedule,,,58.77,,,fee schedule,,,78.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.77,,,fee schedule,,,58.77,,,fee schedule,,,58.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,58.77,,,fee schedule,,,,,,,,,,,,,,,58.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
RIG-HT FOR IM/SQ,2500032806,CDM,636,RC,90376,CPT,4928119020,NDC,,,,inpatient,facility,2,ML,2986.93,2986.93,238.95,2986.93,,,,,,,,,,,,,,2986.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2986.93,,,percent of total billed charges,,,,,,,,,2986.93,,,percent of total billed charges,,,1525.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2543.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1792.16,,,percent of total billed charges,,,,,,,,,,,,,,,2986.93,,,percent of total billed charges,,,2538.89,,,percent of total billed charges,,,,,,,,,,,,,,,2986.93,,,percent of total billed charges,,,1586.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1194.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,2986.93,,,percent of total billed charges,,,,,,,,,,,,,,,238.95,,,percent of total billed charges,,,2986.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2986.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1759.9,,,percent of total billed charges,,
RIG-HT FOR IM/SQ,2500032806,CDM,636,RC,90376,CPT,4928119020,NDC,,,,outpatient,facility,2,ML,2986.93,2986.93,173.71,2986.93,,2118.03,,,percent of total billed charges,,,,,,,,,2986.93,,,percent of total billed charges,,,669.68,,,fee schedule,,,633.56,,,fee schedule,,,,,,,,,633.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,2986.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,,,,,,,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,173.71,,,fee schedule,,,2986.93,,,fee schedule,,,2986.93,,,percent of total billed charges,,,,,,,,,2986.93,,,percent of total billed charges,,,1830.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2128.19,,,percent of total billed charges,,,,,,,,,,,,,,,479.72,,,fee schedule,,,479.72,,,fee schedule,,,479.72,,,fee schedule,,,,,,,,,1762.29,,,percent of total billed charges,,,548.68,,,per diem,,,2986.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,2986.93,,,percent of total billed charges,,,2538.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1586.36,,,percent of total billed charges,,,2986.93,,,percent of total billed charges,,,2986.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2014.98,,,percent of total billed charges,,,2417.02,,,percent of total billed charges,,,,,,,,,,,,,,,1194.77,,,percent of total billed charges,,,,,,,,,800.29,,,fee schedule,,,575.87,,,fee schedule,,,,,,,,,2986.93,,,percent of total billed charges,,,,,,,,,,,,,,,238.95,,,percent of total billed charges,,,2986.93,,,percent of total billed charges,,,,,,,,,,,,,,,2986.93,,,percent of total billed charges,,,2986.93,,,percent of total billed charges,,,,,,,,,342.01,,,fee schedule,,,,,,,,,,,,,,,296.42,,,fee schedule,,,395.23,,,fee schedule,,,222.31,,,fee schedule,,,497.83,,,fee schedule,,,2986.93,,,percent of total billed charges,,,2986.93,,,percent of total billed charges,,,2986.93,,,percent of total billed charges,,,,,,,,,2094.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1493.46,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,,,,,,service not payable
RIG-HT FOR IM/SQ,2500032806,CDM,636,RC,90376,CPT,4928119020,NDC,9134,APC,,outpatient,facility,2,ML,2986.93,2986.93,333.43,1093.22,,,,,,,,357.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,347.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.79,,,fee schedule,,,,,,,,,1093.22,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,347.32,,,fee schedule,,,,,,,,,,,,,,,364.69,,,fee schedule,,,364.69,,,fee schedule,,,,,,,,,347.32,,,fee schedule,,,347.32,,,fee schedule,,,364.69,,,fee schedule,,,,,,,,,,,,,,,520.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,347.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,333.43,,,fee schedule,,,371.63,,,fee schedule,,,364.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,347.32,,,fee schedule,,,347.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,361.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,347.32,,,fee schedule,,,,,,,,,434.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,434.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,,,,,,,,,,,,,347.32,,,fee schedule,,,347.32,,,fee schedule,,,,,,,,,,,,,,,347.32,,,fee schedule,,,,,,,,,347.32,,,fee schedule,,,357.74,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,347.32,,,fee schedule,,,,,,,,,,,,,,,361.21,,,fee schedule,,,347.32,,,fee schedule,,,,,,,,,347.32,,,fee schedule,,,,,,,,,347.32,,,fee schedule,,,364.69,,,fee schedule,,,,,,,,
RIG-HT FOR IM/SQ,2500032806,CDM,636,RC,90376,CPT,4928119020,NDC,460,EAPG,,outpatient,facility,2,ML,2986.93,2986.93,1604.23,2422.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2422.39,,,fee schedule,,,1604.23,,,fee schedule,,,2153.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,1604.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
INFLUENZA VAC FLUAD 0.5ML PF,2500032901,CDM,636,RC,90694,CPT,,,,,,inpatient,facility,1,UN,221.86,221.86,17.75,221.86,,,,,,,,,,,,,,221.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.86,,,percent of total billed charges,,,,,,,,,221.86,,,percent of total billed charges,,,113.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.12,,,percent of total billed charges,,,,,,,,,,,,,,,221.86,,,percent of total billed charges,,,188.58,,,percent of total billed charges,,,,,,,,,,,,,,,221.86,,,percent of total billed charges,,,117.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,221.86,,,percent of total billed charges,,,,,,,,,,,,,,,17.75,,,percent of total billed charges,,,221.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,221.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.72,,,percent of total billed charges,,
INFLUENZA VAC FLUAD 0.5ML PF,2500032901,CDM,636,RC,90694,CPT,,,,,,outpatient,facility,1,UN,221.86,221.86,17.75,548.68,,157.32,,,percent of total billed charges,,,42.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,221.86,,,percent of total billed charges,,,100.41,,,fee schedule,,,95,,,fee schedule,,,41.31,,,fee schedule,,,95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,221.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.72,,,fee schedule,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,41.31,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,221.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,221.86,,,fee schedule,,,221.86,,,percent of total billed charges,,,41.31,,,fee schedule,,,221.86,,,percent of total billed charges,,,135.98,,,percent of total billed charges,,,43.38,,,fee schedule,,,43.38,,,fee schedule,,,,,,,,,42.15,,,fee schedule,,,41.31,,,fee schedule,,,43.38,,,fee schedule,,,158.08,,,percent of total billed charges,,,,,,,,,61.96,,,fee schedule,,,77.36,,,fee schedule,,,77.36,,,fee schedule,,,77.36,,,fee schedule,,,42.54,,,fee schedule,,,130.9,,,percent of total billed charges,,,548.68,,,per diem,,,221.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,221.86,,,percent of total billed charges,,,188.58,,,percent of total billed charges,,,39.86,,,fee schedule,,,44.2,,,fee schedule,,,44.26,,,fee schedule,,,117.83,,,percent of total billed charges,,,221.86,,,percent of total billed charges,,,221.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.31,,,fee schedule,,,41.31,,,fee schedule,,,149.67,,,percent of total billed charges,,,179.53,,,percent of total billed charges,,,,,,,,,43.84,,,fee schedule,,,88.74,,,percent of total billed charges,,,,,,,,,176.12,,,fee schedule,,,126.73,,,fee schedule,,,41.31,,,fee schedule,,,221.86,,,percent of total billed charges,,,51.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,51.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,17.75,,,percent of total billed charges,,,221.86,,,percent of total billed charges,,,41.31,,,fee schedule,,,61.96,,,fee schedule,,,221.86,,,percent of total billed charges,,,221.86,,,percent of total billed charges,,,41.31,,,fee schedule,,,75.26,,,fee schedule,,,41.31,,,fee schedule,,,42.55,,,fee schedule,,,65.24,,,fee schedule,,,86.98,,,fee schedule,,,48.92,,,fee schedule,,,80.28,,,fee schedule,,,221.86,,,percent of total billed charges,,,221.86,,,percent of total billed charges,,,221.86,,,percent of total billed charges,,,67.91,,,fee schedule,,,155.55,,,percent of total billed charges,,,41.31,,,fee schedule,,,44.05,,,fee schedule,,,41.31,,,fee schedule,,,41.31,,,fee schedule,,,42.15,,,fee schedule,,,110.93,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,42.15,,,fee schedule,,,43.38,,,fee schedule,,,130.72,,,percent of total billed charges,,
INFLUENZA VAC FLUAD 0.5ML PF,2500032901,CDM,636,RC,90694,CPT,414,EAPG,,,,outpatient,facility,1,UN,221.86,221.86,24.55,37.07,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.07,,,fee schedule,,,24.55,,,fee schedule,,,32.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,24.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
ALOGLIPTIN 25 MG TAB,2500032904,CDM,637,RC,4580215065,NDC,,,,,,inpatient,facility,25,UN,25.74,25.74,2.06,25.74,,,,,,,,,,,,,,25.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.74,,,percent of total billed charges,,,,,,,,,25.74,,,percent of total billed charges,,,13.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.44,,,percent of total billed charges,,,,,,,,,,,,,,,25.74,,,percent of total billed charges,,,21.88,,,percent of total billed charges,,,,,,,,,,,,,,,25.74,,,percent of total billed charges,,,13.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,25.74,,,percent of total billed charges,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.17,,,percent of total billed charges,,
ALOGLIPTIN 25 MG TAB,2500032904,CDM,637,RC,4580215065,NDC,,,,,,outpatient,facility,25,UN,25.74,25.74,2.06,548.68,,18.25,,,percent of total billed charges,,,6.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,25.74,,,percent of total billed charges,,,16.13,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,18.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,18.1,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,25.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,9.42,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,25.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,25.74,,,fee schedule,,,25.74,,,percent of total billed charges,,,,,,,,,25.74,,,percent of total billed charges,,,15.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.34,,,percent of total billed charges,,,,,,,,,,,,,,,13.9,,,percent of total billed charges,,,13.38,,,percent of total billed charges,,,14.16,,,percent of total billed charges,,,,,,,,,15.19,,,percent of total billed charges,,,548.68,,,per diem,,,25.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,25.74,,,percent of total billed charges,,,21.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.67,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.36,,,percent of total billed charges,,,20.83,,,percent of total billed charges,,,,,,,,,,,,,,,10.3,,,percent of total billed charges,,,,,,,,,9.52,,,percent of total billed charges,,,9.52,,,percent of total billed charges,,,,,,,,,25.74,,,percent of total billed charges,,,25.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,25.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,2.06,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,,,,,,,,,,,,,25.74,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,,,,,,,23.94,,,percent of total billed charges,,,,,,,,,,,,,,,23.94,,,percent of total billed charges,,,23.94,,,percent of total billed charges,,,23.94,,,percent of total billed charges,,,19.3,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,25.74,,,percent of total billed charges,,,,,,,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.87,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,15.17,,,percent of total billed charges,,
ALOGLIPTIN 25 MG TAB,2500032904,CDM,637,RC,4580215065,NDC,999,EAPG,,,,outpatient,facility,25,UN,25.74,25.74,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
FENTANYL 2MCG/BUP 0.125 250ML,2500032911,CDM,636,RC,,,,,,,,inpatient,facility,250,UN,206.68,206.68,16.53,206.68,,,,,,,,,,,,,,206.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.68,,,percent of total billed charges,,,,,,,,,206.68,,,percent of total billed charges,,,105.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,,,,,,,,,,206.68,,,percent of total billed charges,,,175.68,,,percent of total billed charges,,,,,,,,,,,,,,,206.68,,,percent of total billed charges,,,109.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,206.68,,,percent of total billed charges,,,,,,,,,,,,,,,16.53,,,percent of total billed charges,,,206.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,206.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.78,,,percent of total billed charges,,
FENTANYL 2MCG/BUP 0.125 250ML,2500032911,CDM,636,RC,,,,,,,,outpatient,facility,250,UN,206.68,206.68,16.53,548.68,,146.56,,,percent of total billed charges,,,50.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,206.68,,,percent of total billed charges,,,129.53,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,145.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,145.3,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,206.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,75.64,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,206.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,206.68,,,fee schedule,,,206.68,,,percent of total billed charges,,,,,,,,,206.68,,,percent of total billed charges,,,126.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.26,,,percent of total billed charges,,,,,,,,,,,,,,,111.61,,,percent of total billed charges,,,107.47,,,percent of total billed charges,,,113.67,,,percent of total billed charges,,,,,,,,,121.94,,,percent of total billed charges,,,548.68,,,per diem,,,206.68,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,206.68,,,percent of total billed charges,,,175.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.77,,,percent of total billed charges,,,206.68,,,percent of total billed charges,,,206.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.43,,,percent of total billed charges,,,167.25,,,percent of total billed charges,,,,,,,,,,,,,,,82.67,,,percent of total billed charges,,,,,,,,,82.67,,,percent of total billed charges,,,82.67,,,percent of total billed charges,,,,,,,,,206.68,,,percent of total billed charges,,,206.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,206.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,16.53,,,percent of total billed charges,,,206.68,,,percent of total billed charges,,,,,,,,,,,,,,,206.68,,,percent of total billed charges,,,206.68,,,percent of total billed charges,,,,,,,,,82.67,,,percent of total billed charges,,,,,,,,,,,,,,,82.67,,,percent of total billed charges,,,82.67,,,percent of total billed charges,,,82.67,,,percent of total billed charges,,,155.01,,,percent of total billed charges,,,206.68,,,percent of total billed charges,,,206.68,,,percent of total billed charges,,,206.68,,,percent of total billed charges,,,,,,,,,144.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.34,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,121.78,,,percent of total billed charges,,
FENTANYL 2MCG/BUP 0.125 250ML,2500032911,CDM,636,RC,999,EAPG,,,,,,outpatient,facility,250,UN,206.68,206.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
LIDOCAINE 5  CRM 30 GM,2500032918,CDM,637,RC,3932802530,NDC,,,,,,inpatient,facility,30,UN,194.7,194.7,15.58,194.7,,,,,,,,,,,,,,194.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.7,,,percent of total billed charges,,,,,,,,,194.7,,,percent of total billed charges,,,99.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.82,,,percent of total billed charges,,,,,,,,,,,,,,,194.7,,,percent of total billed charges,,,165.49,,,percent of total billed charges,,,,,,,,,,,,,,,194.7,,,percent of total billed charges,,,103.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,194.7,,,percent of total billed charges,,,,,,,,,,,,,,,15.58,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,194.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.72,,,percent of total billed charges,,
LIDOCAINE 5  CRM 30 GM,2500032918,CDM,637,RC,3932802530,NDC,,,,,,outpatient,facility,30,UN,194.7,194.7,15.58,548.68,,138.06,,,percent of total billed charges,,,47.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,194.7,,,percent of total billed charges,,,122.02,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,136.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,136.87,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 70.30%  End FormulaCPE End Sum ,,,,,,,,,,,,,,,,,,,,,,,,,194.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,357.82,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $357.82.   If ( Current Amount = 0 )   Then:  $357.82 Flat ,71.26,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,other,,Group (Sum Of):   Is:  Procedure Lookup Tables:    [CELTICARE CHOICE CARVE OUT PROC]     1st procedure and all subsequent procedures payable at 36.60% of charge amount.   Procedures are sorted by charged amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Component Percentages of Standard Medicare OPPS (APC and Fee Schedule) pricing   APC amount: 115%   Pass-through amount: 100%   Outlier amount: 100%   Labs amount: 115%   Therapies/mammography Amount: 115%   DMEPOS Amount: 115%     Use this provider number in place of provider number from claim: 220020     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Pay this percent instead of a zero amount: 33.60%     Percent when code not payable by Medicare: 33.60%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit     Apply sequestration reduction    Ambulance   Override FS - Ground with 115% of fee schedule amount.   Override FS - Air with 115% of fee schedule amount.   Override FS Co-Pay percent with  20% of fee schedule amount. If ( Current Amount = 0 )   Then:  36.60 % of Charges In Service Type ,431.72,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,other,, Daily Charge Grouping: Event properties: UB Lines with Table Code(s): [ALL REVS EXCEPT LAB]  Consume all charges on matched days.  Reimbursement Group: UB Lines with Revenue Code(s):  [ALL REVS EXCEPT LAB]  at Flat Amount of $431.72.   If ( Current Amount = 0 )   Then:  $431.72 Flat ,194.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No reimbursement terms for     Unassigned Charges. Please review. ,194.7,,,fee schedule,,,194.7,,,percent of total billed charges,,,,,,,,,194.7,,,percent of total billed charges,,,119.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.72,,,percent of total billed charges,,,,,,,,,,,,,,,105.14,,,percent of total billed charges,,,101.24,,,percent of total billed charges,,,107.09,,,percent of total billed charges,,,,,,,,,114.87,,,percent of total billed charges,,,548.68,,,per diem,,,194.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,other,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Service not covered under     contract. ,194.7,,,percent of total billed charges,,,165.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.41,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.34,,,percent of total billed charges,,,157.55,,,percent of total billed charges,,,,,,,,,,,,,,,77.88,,,percent of total billed charges,,,,,,,,,72.04,,,percent of total billed charges,,,72.04,,,percent of total billed charges,,,,,,,,,194.7,,,percent of total billed charges,,,194.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,194.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 125.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction   Ambulance  Override provider number: 220020  Override FS - Ground with 125.00% of fee schedule amount.  Override FS - Air with 125.00% of fee schedule amount.  Override FS Co-Pay percent with  20% of fee schedule amount.  Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  100.00 % of Charges In Service Type ,15.58,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,,,,,,,,,,,,,194.7,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,,,,,,,181.11,,,percent of total billed charges,,,,,,,,,,,,,,,181.11,,,percent of total billed charges,,,181.11,,,percent of total billed charges,,,181.11,,,percent of total billed charges,,,146.02,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,,,,,,,136.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.35,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,other,,50.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for     Behavioral Health only. Please review claim. ,,,,,,,,,,,,,114.72,,,percent of total billed charges,,
LIDOCAINE 5  CRM 30 GM,2500032918,CDM,637,RC,3932802530,NDC,999,EAPG,,,,outpatient,facility,30,UN,194.7,194.7,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MENTHOL/METHYL SALIC CRM 57GM,2500032925,CDM,637,RC,7430008193,NDC,,,,,,inpatient,facility,57,UN,14.32,14.32,1.15,14.32,,,,,,,,,,,,,,14.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.32,,,percent of total billed charges,,,,,,,,,14.32,,,percent of total billed charges,,,7.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.59,,,percent of total billed charges,,,,,,,,,,,,,,,14.32,,,percent of total billed charges,,,12.17,,,percent of total billed charges,,,,,,,,,,,,,,,14.32,,,percent of total billed charges,,,7.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,14.32,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,14.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.44,,,percent of total billed charges,,
MENTHOL/METHYL SALIC CRM 57GM,2500032925,CDM,637,RC,7430008193,NDC,,,,,,outpatient,facility,57,UN,14.32,14.32,1.15,548.68,,10.15,,,percent of total billed charges,,,3.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,other,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 103.00% of Medicare total payment    Use this provider number in place of provider number from claim: 220020    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Pay this percent instead of a zero amount: 24.40%    Percent when code not payable by Medicare: 24.40%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit    Apply sequestration reduction If ( Current Amount = 0.00 )   Then:  24.40 % of Charges In Service Type ,14.32,,,percent of total billed charges,,,8.97,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[ANY CODE WITH MOD SL]] 100% of Table Per Unit   Multipliers: 100%   Sort By: Table Amount - Highest   Conditions:    Process Daily: N    Limit reimbursement to 100%    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: No    Additional Modifier Table: Table     [[SL]]    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:Charges of SL Lines} + {iv:Non Payable SI N})) * 62.67%  End FormulaCPE End Sum ,other,,Interim Value: Charges of SL Lines  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE WITH MOD SL]] 100% of Charges  Multipliers: 100%  Sort By: Table Amount - Highest  Conditions:   Process Daily: N   Limit reimbursement to 100%   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Interim Value: Non Payable SI N  Procedure Lookup:  Procedure Code Tables:   [[BCBS ALL OP NON PAYABLE]] $0.00 with Revenue Code Table: [[BCBS BUNDLED REV CODES]]   [[BCBS ALL OP NON PAYABLE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: 